J AM ACAD DERMATOL
Letters 199
VOLUME 71, NUMBER 1
We extended our previous study to embrace 61 women with clinically diagnosed gestational PR. HHV-6/7 DNA was assessed in skin lesions, plasma, and placenta in 14 consenting patients (4 miscarriages, 5 with perinatal problems, 5 without perinatal problems), as well as in fetal tissue, by quantitative calibrated real-time polymerase chain reaction.5 Specific HHV-6 and HHV-7 serology was appraised by indirect immunofluorescence in all 61 patients. Of the 61 women, 22 had unfavorable outcomes. Eight miscarried (Table I). All miscarrying women had atypical PR (skin lesions unusually widespread and long duration with constitutional symptoms associated). None of them had risk factors for intrauterine fetal death. All 61 patients carried HHV-6/7 IgG, but none had detectable IgM antibodies. HHV-6 DNA was found in plasma in 3 of 4 women with stillborns, in the placenta and in PR lesions in 4 women, and in fetal tissue in 3 of 4 stillborns (Table I). Only in 1 of 5 women with perinatal problems was HHV-6 DNA found in plasma, PR lesions, and placenta. HHV-6 DNA was detected in plasma in 2 of 5 PR patients with normal pregnancies. Notably, none of the placenta and only 1 of the PR lesions was positive for HHV-6 DNA in the PR patients with normal pregnancies. HHV-7 DNA was detected in plasma and PR lesions in 3 miscarrying women, but never in fetal tissues. In women with perinatal problems, HHV-7 was found in plasma (1 patient), in placenta (2 patients), and in PR lesions (3 patients). HHV-7 was found in women with normal pregnancies as well (3 cases in plasma, 2 in PR lesions, none in placenta). Histopathology revealed villitis, chorioamnionitis, or funisitis in all stillborns, in 3 of 5 women with perinatal problems, and in 1 of 5 women without perinatal problems. No fetal chromosomal abnormalities were present. Our study suggests that PR developing during pregnancy may be followed by premature delivery and even fetal death. On the whole, the total abortion rate we found (8 of 61, 13%) was the same as in our previous study (5 of 38, 13%).5 Noteworthy, when PR developed within the 15th gestational week (14 cases), we observed an abortion rate of 57% (8 of 14). This finding is comparable to our previous series (62%),5 suggesting that the early reactivation of HHV-6 is critical for the outcome of pregnancy. Therefore, in women in whom PR develops during the first 15 weeks of gestation, especially with atypical PR forms, a closer followup should be recommended.
Francesco Drago, MD,a Francesco Broccolo, MD,b Sanja Javor, MD,a Francesca Drago,a Alfredo Rebora, MD,a and Aurora Parodi, MDa Department of Endocrinological and Metabolic Sciences, Section of Dermatology, University of Genoa,a and Department of Health Sciences, University of Milano-Bicocca,b Italy Funding sources: None. Conflicts of interest: None declared. Correspondence to: Sanja Javor, MD, Department of Endocrinological and Metabolic Sciences, Section of Dermatology, University of Genoa, Viale Benedetto XV, 7-16132 Genoa, Italy E-mail: [email protected] REFERENCES 1. Broccolo F, Drago F, Careddu AM, Foglieni C, Turbino L, Cocuzza CE, et al. Additional evidence that pityriasis rosea is associated with reactivation of human herpes virus-6 and -7. J Invest Dermatol 2005;124:1234-40. 2. Watanabe T, Kawamura T, Jacob SE, Aquilino EA, Orenstein JM, Black JB, et al. Pityriasis rosea is associated with systemic active infection with both human herpesvirus-7 and human herpesvirus-6. J Invest Dermatol 2002;119: 793-7. 3. Ohashi M, Yoshikawa T, Ihira M, Suzuki K, Suga S, Tada S, et al. Reactivation of human herpesvirus 6 and 7 in pregnant women. J Med Virol 2002;67:354-8. 4. Dahl H, Fjaertoft G, Norsted T, Wang FZ, Mousavi-Jazi M, Linde A. Reactivation of human herpesvirus 6 during pregnancy. J Infect Dis 1999;180:2035-8. 5. Drago F, Broccolo F, Zaccaria E, Malnati M, Cocuzza C, Lusso P, et al. Pregnancy outcome in patients with pityriasis rosea. J Am Acad Dermatol 2008;58:78-83. http://dx.doi.org/10.1016/j.jaad.2014.02.023
Buying indoor tanning with university debit cards To the Editor: The booming indoor tanning industry in the United States has approximately 19,000 facilities and 160,000 employees serving 10% of the population annually.1 According to a recent study, among US college students, ever and past-year exposure to indoor tanning has been reported at 55% and 43%, respectively.2 Many universities sponsor debit cards for paying student expenses. Frequently, parents fund these cards, which are accepted only by vendors who enter into agreements with the university. We became aware of university debit card use at indoor tanning facilities through focus groups and interviews conducted in 2013 with 40 young adult tanners. Tanners uniformly reported to us that cost is among the major factors influencing decisions to use indoor tanning. The option to use debit cards at tanning facilities may reduce the
J AM ACAD DERMATOL
200 Letters
JULY 2014
Table I. University debit cards associated with tanning salon merchants State
Alabama Georgia Illinois Indiana Kentucky Michigan Mississippi New Hampshire New Jersey Ohio Pennsylvania South Carolina Texas Vermont Virginia
University
Total undergraduates
Number of tanning salon merchants
University of Alabama University of Georgia Georgia Southern University University of Illinois at Urbana-Champaign Indiana University Western Kentucky University Michigan State University The University of Mississippi University of New Hampshire Southern New Hampshire University Rutgers, The State University of New Jersey: New Brunswick/Piscataway Campus Ohio State University: Columbus Campus Penn State University Park University of Pittsburgh Clemson University University of Texas at Austin University of Vermont Virginia Polytechnic Institute and State University
28,026 26,259 17,993 32,281 32,371 18,101 37,454 16,060 12,811 11,253 31,593
1 2 2 2 2 1 3 3 1 1 4
14,432 39,193 18,429 16,562 39,995 11,211 23,859
3 8 1 2 1 1 2
Fig 1. Black pins represent the location of universities with debit cards that list indoor UV tanning salons as merchants.
immediate impact of cost as a barrier. We investigated the degree to which university-sponsored debit cards include indoor ultraviolet (UV) tanning merchants as accepted vendors. Two authors (LB and CK) collected data independently during October 2013, with consensus review to resolve discrepancies. The 2 4-year, residential universities with the largest number of undergraduates in each state were identified through Collegeboard.org. Google and .edu website searches determined whether each university offers a debit card for students and, if so, whether tanning salons were listed as associated merchants. The availability of UV tanning at any listed tanning salon was verified
by calling or visiting the tanning salon website. This study was reviewed and approved by the Colorado Multiple Institutional Review Board (Protocol 13-0043). Overall, 97.9% of the universities (94 of 96) sponsored student debit cards, with 4 states (Alaska, Hawaii, Nevada, Wyoming) having only 1 university that met the inclusion criteria. Eighteen universities with debit cards identified tanning salons as merchants (Table I) and 11 had agreements with multiple indoor tanning salons (range, 1 to 8; median, 2). Pennsylvania State University and Rutgers University, NJ, listed the most tanning salons (8 and 4, respectively). Universities linked with
J AM ACAD DERMATOL VOLUME 71, NUMBER 1
tanning salons are concentrated exclusively in the east and south of the United States (Fig 1). Combined, the 18 universities with tanning salon agreements have an undergraduate population of more than 400,000, highlighting the enormous reach of university debit card financial agreements. These agreements constitute an endorsement and even encourage indoor tanning, which has been designated as a carcinogen by the World Health Organization.3 We call for all universities to dissolve associations between their university debit card programs and indoor tanning salons. With mounting evidence of the carcinogenic potential of indoor tanning, policies should be enacted following the lead of the anti-tobacco movement.4 The tobacco and tanning industries market addictive carcinogenic products to young adults and advance their industries via advocacy groups and lobbyists.4 The MPOWER model (monitor, protect, offer alternatives, warn, enforce, and raise taxes) that has been used for tobacco control is applicable to indoor tanning.4 The urgency and importance of ending relationships between universities and tanning salons is critical for the health of young adults and the reduction of skin cancer. Lindsay Boyers, BA,a Chante Karimkhani, BA,b Lori A. Crane, PhD, MPH,c Nancy Asdigian, PhD,c Adrienn Hollonds, MHS, CLE,c and Robert P. Dellavalle, MD, PhD, MSPHc,d,e Georgetown University School of Medicine,a Washington, DC; Columbia University College of Physicians and Surgeons,b New York, New York; Department of Community and Behavioral Health, Colorado School of Public Health,c and Department of Dermatology,d University of Colorado Anschutz Medical Campus, Aurora; and Dermatology Service, Eastern Colorado Health Care System, US Department of Veteran Affairs,e Denver, Colorado Funding sources: Centers for Disease Control and Prevention (CDC) grant number 3U48DP001938-04S1 to Lori Crane. Disclosure: Robert Dellavalle chairs the Colorado Skin Cancer Prevention Task Force and was a
Letters 201
staff physician supported by the US Department of Veterans Affairs at the time of the study and manuscript preparation. Lori Crane, Nancy Asdigian, and Robert Dellavalle are supported by grants from the CDC and National Institutes of Health. Adrienn Hollonds is supported by grants from the CDC. Lindsay Boyers was employed without compensation at the Department of Veterans Affairs at the time of this study. Chante Karimkhani reports no relevant disclosures. The CDC, Department of Veterans Affairs, and National Institutes of Health were not directly involved in study design, data acquisition and interpretation, manuscript preparation, or review. Any opinions expressed herein do not necessarily reflect the opinions of the CDC or the Department of Veterans Affairs. The CDC, US Department of Veterans Affairs, and National Institutes of Health had no role in the design and conduct of the study; collections, management, analysis and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Correspondence to: Robert P. Dellavalle, MD, PhD, MSPH, Chief, Dermatology Service, Department of Veteran Affairs Medical Center, 1055 Clermont Street, Box 165, Denver, CO 80220 E-mail: [email protected] REFERENCES 1. Indoor Tanning Association. FAQs. http://www.theita.com/? page¼FAQs. Accessed October 22, 2013. 2. Wehner MR, Chren M, Nameth D, Choudhry A, Gaskins M, Nead KT, et al. International prevalence of indoor tanning: a systematic review and meta-analysis. JAMA Dermatol doi:10.1001/jamader matol.2013.6896. Published online January 29, 2014. 3. Sinclair C. World Health Organization. Artificial tanning sunbeds: risk and guidance. Available from: http://www.who.int/ uv/publications/sunbedpubl/en/. Accessed November 21, 2013. 4. Centers for Disease Control and Prevention. Implications of lessons learned from tobacco control for tanning bed reform. http://www.cdc.gov/pcd/issues/2013/12_0186.htm. Accessed October 25, 2013. http://dx.doi.org/10.1016/j.jaad.2014.02.041
Letters 199
VOLUME 71, NUMBER 1
We extended our previous study to embrace 61 women with clinically diagnosed gestational PR. HHV-6/7 DNA was assessed in skin lesions, plasma, and placenta in 14 consenting patients (4 miscarriages, 5 with perinatal problems, 5 without perinatal problems), as well as in fetal tissue, by quantitative calibrated real-time polymerase chain reaction.5 Specific HHV-6 and HHV-7 serology was appraised by indirect immunofluorescence in all 61 patients. Of the 61 women, 22 had unfavorable outcomes. Eight miscarried (Table I). All miscarrying women had atypical PR (skin lesions unusually widespread and long duration with constitutional symptoms associated). None of them had risk factors for intrauterine fetal death. All 61 patients carried HHV-6/7 IgG, but none had detectable IgM antibodies. HHV-6 DNA was found in plasma in 3 of 4 women with stillborns, in the placenta and in PR lesions in 4 women, and in fetal tissue in 3 of 4 stillborns (Table I). Only in 1 of 5 women with perinatal problems was HHV-6 DNA found in plasma, PR lesions, and placenta. HHV-6 DNA was detected in plasma in 2 of 5 PR patients with normal pregnancies. Notably, none of the placenta and only 1 of the PR lesions was positive for HHV-6 DNA in the PR patients with normal pregnancies. HHV-7 DNA was detected in plasma and PR lesions in 3 miscarrying women, but never in fetal tissues. In women with perinatal problems, HHV-7 was found in plasma (1 patient), in placenta (2 patients), and in PR lesions (3 patients). HHV-7 was found in women with normal pregnancies as well (3 cases in plasma, 2 in PR lesions, none in placenta). Histopathology revealed villitis, chorioamnionitis, or funisitis in all stillborns, in 3 of 5 women with perinatal problems, and in 1 of 5 women without perinatal problems. No fetal chromosomal abnormalities were present. Our study suggests that PR developing during pregnancy may be followed by premature delivery and even fetal death. On the whole, the total abortion rate we found (8 of 61, 13%) was the same as in our previous study (5 of 38, 13%).5 Noteworthy, when PR developed within the 15th gestational week (14 cases), we observed an abortion rate of 57% (8 of 14). This finding is comparable to our previous series (62%),5 suggesting that the early reactivation of HHV-6 is critical for the outcome of pregnancy. Therefore, in women in whom PR develops during the first 15 weeks of gestation, especially with atypical PR forms, a closer followup should be recommended.
Francesco Drago, MD,a Francesco Broccolo, MD,b Sanja Javor, MD,a Francesca Drago,a Alfredo Rebora, MD,a and Aurora Parodi, MDa Department of Endocrinological and Metabolic Sciences, Section of Dermatology, University of Genoa,a and Department of Health Sciences, University of Milano-Bicocca,b Italy Funding sources: None. Conflicts of interest: None declared. Correspondence to: Sanja Javor, MD, Department of Endocrinological and Metabolic Sciences, Section of Dermatology, University of Genoa, Viale Benedetto XV, 7-16132 Genoa, Italy E-mail: [email protected] REFERENCES 1. Broccolo F, Drago F, Careddu AM, Foglieni C, Turbino L, Cocuzza CE, et al. Additional evidence that pityriasis rosea is associated with reactivation of human herpes virus-6 and -7. J Invest Dermatol 2005;124:1234-40. 2. Watanabe T, Kawamura T, Jacob SE, Aquilino EA, Orenstein JM, Black JB, et al. Pityriasis rosea is associated with systemic active infection with both human herpesvirus-7 and human herpesvirus-6. J Invest Dermatol 2002;119: 793-7. 3. Ohashi M, Yoshikawa T, Ihira M, Suzuki K, Suga S, Tada S, et al. Reactivation of human herpesvirus 6 and 7 in pregnant women. J Med Virol 2002;67:354-8. 4. Dahl H, Fjaertoft G, Norsted T, Wang FZ, Mousavi-Jazi M, Linde A. Reactivation of human herpesvirus 6 during pregnancy. J Infect Dis 1999;180:2035-8. 5. Drago F, Broccolo F, Zaccaria E, Malnati M, Cocuzza C, Lusso P, et al. Pregnancy outcome in patients with pityriasis rosea. J Am Acad Dermatol 2008;58:78-83. http://dx.doi.org/10.1016/j.jaad.2014.02.023
Buying indoor tanning with university debit cards To the Editor: The booming indoor tanning industry in the United States has approximately 19,000 facilities and 160,000 employees serving 10% of the population annually.1 According to a recent study, among US college students, ever and past-year exposure to indoor tanning has been reported at 55% and 43%, respectively.2 Many universities sponsor debit cards for paying student expenses. Frequently, parents fund these cards, which are accepted only by vendors who enter into agreements with the university. We became aware of university debit card use at indoor tanning facilities through focus groups and interviews conducted in 2013 with 40 young adult tanners. Tanners uniformly reported to us that cost is among the major factors influencing decisions to use indoor tanning. The option to use debit cards at tanning facilities may reduce the
J AM ACAD DERMATOL
200 Letters
JULY 2014
Table I. University debit cards associated with tanning salon merchants State
Alabama Georgia Illinois Indiana Kentucky Michigan Mississippi New Hampshire New Jersey Ohio Pennsylvania South Carolina Texas Vermont Virginia
University
Total undergraduates
Number of tanning salon merchants
University of Alabama University of Georgia Georgia Southern University University of Illinois at Urbana-Champaign Indiana University Western Kentucky University Michigan State University The University of Mississippi University of New Hampshire Southern New Hampshire University Rutgers, The State University of New Jersey: New Brunswick/Piscataway Campus Ohio State University: Columbus Campus Penn State University Park University of Pittsburgh Clemson University University of Texas at Austin University of Vermont Virginia Polytechnic Institute and State University
28,026 26,259 17,993 32,281 32,371 18,101 37,454 16,060 12,811 11,253 31,593
1 2 2 2 2 1 3 3 1 1 4
14,432 39,193 18,429 16,562 39,995 11,211 23,859
3 8 1 2 1 1 2
Fig 1. Black pins represent the location of universities with debit cards that list indoor UV tanning salons as merchants.
immediate impact of cost as a barrier. We investigated the degree to which university-sponsored debit cards include indoor ultraviolet (UV) tanning merchants as accepted vendors. Two authors (LB and CK) collected data independently during October 2013, with consensus review to resolve discrepancies. The 2 4-year, residential universities with the largest number of undergraduates in each state were identified through Collegeboard.org. Google and .edu website searches determined whether each university offers a debit card for students and, if so, whether tanning salons were listed as associated merchants. The availability of UV tanning at any listed tanning salon was verified
by calling or visiting the tanning salon website. This study was reviewed and approved by the Colorado Multiple Institutional Review Board (Protocol 13-0043). Overall, 97.9% of the universities (94 of 96) sponsored student debit cards, with 4 states (Alaska, Hawaii, Nevada, Wyoming) having only 1 university that met the inclusion criteria. Eighteen universities with debit cards identified tanning salons as merchants (Table I) and 11 had agreements with multiple indoor tanning salons (range, 1 to 8; median, 2). Pennsylvania State University and Rutgers University, NJ, listed the most tanning salons (8 and 4, respectively). Universities linked with
J AM ACAD DERMATOL VOLUME 71, NUMBER 1
tanning salons are concentrated exclusively in the east and south of the United States (Fig 1). Combined, the 18 universities with tanning salon agreements have an undergraduate population of more than 400,000, highlighting the enormous reach of university debit card financial agreements. These agreements constitute an endorsement and even encourage indoor tanning, which has been designated as a carcinogen by the World Health Organization.3 We call for all universities to dissolve associations between their university debit card programs and indoor tanning salons. With mounting evidence of the carcinogenic potential of indoor tanning, policies should be enacted following the lead of the anti-tobacco movement.4 The tobacco and tanning industries market addictive carcinogenic products to young adults and advance their industries via advocacy groups and lobbyists.4 The MPOWER model (monitor, protect, offer alternatives, warn, enforce, and raise taxes) that has been used for tobacco control is applicable to indoor tanning.4 The urgency and importance of ending relationships between universities and tanning salons is critical for the health of young adults and the reduction of skin cancer. Lindsay Boyers, BA,a Chante Karimkhani, BA,b Lori A. Crane, PhD, MPH,c Nancy Asdigian, PhD,c Adrienn Hollonds, MHS, CLE,c and Robert P. Dellavalle, MD, PhD, MSPHc,d,e Georgetown University School of Medicine,a Washington, DC; Columbia University College of Physicians and Surgeons,b New York, New York; Department of Community and Behavioral Health, Colorado School of Public Health,c and Department of Dermatology,d University of Colorado Anschutz Medical Campus, Aurora; and Dermatology Service, Eastern Colorado Health Care System, US Department of Veteran Affairs,e Denver, Colorado Funding sources: Centers for Disease Control and Prevention (CDC) grant number 3U48DP001938-04S1 to Lori Crane. Disclosure: Robert Dellavalle chairs the Colorado Skin Cancer Prevention Task Force and was a
Letters 201
staff physician supported by the US Department of Veterans Affairs at the time of the study and manuscript preparation. Lori Crane, Nancy Asdigian, and Robert Dellavalle are supported by grants from the CDC and National Institutes of Health. Adrienn Hollonds is supported by grants from the CDC. Lindsay Boyers was employed without compensation at the Department of Veterans Affairs at the time of this study. Chante Karimkhani reports no relevant disclosures. The CDC, Department of Veterans Affairs, and National Institutes of Health were not directly involved in study design, data acquisition and interpretation, manuscript preparation, or review. Any opinions expressed herein do not necessarily reflect the opinions of the CDC or the Department of Veterans Affairs. The CDC, US Department of Veterans Affairs, and National Institutes of Health had no role in the design and conduct of the study; collections, management, analysis and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Correspondence to: Robert P. Dellavalle, MD, PhD, MSPH, Chief, Dermatology Service, Department of Veteran Affairs Medical Center, 1055 Clermont Street, Box 165, Denver, CO 80220 E-mail: [email protected] REFERENCES 1. Indoor Tanning Association. FAQs. http://www.theita.com/? page¼FAQs. Accessed October 22, 2013. 2. Wehner MR, Chren M, Nameth D, Choudhry A, Gaskins M, Nead KT, et al. International prevalence of indoor tanning: a systematic review and meta-analysis. JAMA Dermatol doi:10.1001/jamader matol.2013.6896. Published online January 29, 2014. 3. Sinclair C. World Health Organization. Artificial tanning sunbeds: risk and guidance. Available from: http://www.who.int/ uv/publications/sunbedpubl/en/. Accessed November 21, 2013. 4. Centers for Disease Control and Prevention. Implications of lessons learned from tobacco control for tanning bed reform. http://www.cdc.gov/pcd/issues/2013/12_0186.htm. Accessed October 25, 2013. http://dx.doi.org/10.1016/j.jaad.2014.02.041
