Rob Steele, MD (Host): Welcome to Pediatrics in Practice, a CME podcast. I'm your host, Dr. Rob Steele, Executive Vice President and Chief Strategy and Innovation Officer at Children's Mercy, Kansas City. Before we introduce our guest, I wanted to remind you to claim your CME credits after listening to today's episode. You can do so by visiting cmkc.link/cmepodcast and click the Claim CME button.

Today, we are joined by Stephanie Kronberg to talk about skin safety in the summer months. How appropriate, given that we are in May heading into the summer months. Stephanie is a nurse practitioner in Dermatology at Children's Mercy, Kansas City and just celebrated her 10-year work anniversary. Congratulations. She has presented at multiple conferences, including the National Association for Pediatric Nurse Practitioners, also known as NAPNAP, the conference in 2020, and the Children's Mercy Annual School Health Conference from 2015 and 2022. Stephanie earned her APRN III promotion in 2021, a promotion program based on clinical experience, academic preparation, and professional engagement. Stephanie also received the Advanced Practice Clinical Care Achievement Award in October of 2021.

Stephanie is interested in the psychosocial issues that skin conditions can have on children and is currently working on two different quality improvement projects which focus on improving quality of life in children with those skin conditions. Stephanie, thank you for joining us today.

Stephanie Kronberg: Yes, thanks so much for having me.

Host: I have to ask you before we get started, you grew up in Minneapolis, Minnesota. I have a friend from Minneapolis, Minnesota who said that Minneapolis is a great place because it has great weather for those who live there, but it's cold enough to keep the riffraff out. Is that a fair statement?

Stephanie Kronberg: I totally agree. I think I have said that before too.

Host: I told him that I count as the riffraff because there's no way that I could survive there. Well, welcome to the show. It's great to have you. And as I mentioned in the intro, we are currently moving into the summer months. And so, this is very timely. So, let me go ahead and just jump right in. And can you give us just some general reminders about sun protection for the summer months, things to consider like sunscreen, sun protection, maybe the myths that are around sunscreen and sun protection?

Stephanie Kronberg: Yeah, definitely. So yeah, like you said, schools are getting out, pools are starting to open, and kids are going to be spending a lot more time outside in the sun. So, it's a great time to talk about sun protection. I think we all know that sun protection is really important. The sun is a source of radiation and it comes in two forms, UVA and UVB rays. Both of these can be damaging and both can lead to aging, but then also skin cancer. I think that's the thing we're most worried about. And kids don't get skin cancer very often, but it's really important to start protecting their skin in childhood, so that they have less risk of developing skin cancer as they get older.

So, some different ways to protect the skin from the sun are avoiding outdoor activities during the peak hours, seeking shade, choosing clothing and swimwear that has UV protection. So, we always recommend long-sleeved swim shirts for kids if you can get them to wear them, and just kind of getting in that habit of having kids wear shirts when they swim. Hats can be really helpful as well. So, it's also helpful if parents can wear hats when they're in the sun just to be kind of a good example. That can help to protect the scalp and then part of the face and neck as well. Sunglasses are important to help protect the eyes from sun damage.

And then, of course, sunscreen is a great tool for protecting the skin in areas that aren't protected by clothing. And it can definitely be a pain to apply sunscreen. I get annoyed by it too. And putting it on my kids every day, it can definitely be a pain, but it's best to just try to make it a routine. So just like kids always wear a seatbelt when they're in the car, and a helmet when they're biking, they should wear sunscreen every day before they leave the house.

As far as like which sunscreen to use, people are always asking about creams versus sprays. We usually recommend creams and lotions just because the sprays, if you've ever seen somebody spray sunscreen, most of it goes into the environment. So, you're losing a lot of it. It's a lot easier to miss spots on your skin and to inhale some of it too. I mean, a spray is better than nothing. But if you're going to spray, probably spray it on your hands and then put it on the skin.

Host: Yeah. Just as a user of sunscreen, certainly on my kids as well, it's a lot more economical too to avoid the sprays for sure, because the lotions or the creams go a lot further along. So, it's a lot cheaper that way too.

Stephanie Kronberg: Yeah, that is a very good point. The sprays kind of go pretty quickly. Sticks are nice. If you use sunscreen sticks, those are good for the face and good for around the eyes.

Host: And can you touch a little bit on just the SPF labeling because we joke about getting the SPF 5000, which of course there is none, but the numbers do vary to a large degree. Can you give our listeners a quick primer on the SPF designation?

Stephanie Kronberg: Yeah. So, we typically recommend SPF 30 or more, but you really don't have to go super high just because once you get past 50, it's really not going to protect you much more than the 50 or the 30. And I think the hard part is like some people get SPF 100 or whatever, but then they think it's going to protect them for the whole day. But no, you still need to apply it every two hours.

Host: Yeah. Great point about the reapplication. Again, as a parent, I can tell you it's hard to remember to reapply, particularly in the busyness of a summer day. So, great advice. During the summertime, of course, that's when the bugs come out, you get a lot of insect bites and those types of things. Is there anything for the pediatrician to recommend to their patients with regard to the use of sunscreen alongside these, you know, bug bites and treating the bug bites?

Stephanie Kronberg: Yeah. So if you're in a situation where you're going to use sunscreen and bug spray, you want to do the sunscreen first, followed by the insect repellent. And then, a question we get a lot is about like whether kids can use DEET products, so insect repellents with DEET.

Host: Right.

Stephanie Kronberg: So, they can. The AAP does recommend for newborns up to age two, it's best to use 100% DEET. But then, after two years of age, you can go up to 30% DEET. And so, the higher percentage, the longer it's going to last.

Host: Yeah. And my experience has been, you know, for those children that can have the higher levels of DEET, those are sometimes harder to find in the stores. You have to sometimes go to outdoor stores and whatnot. I don't know if that's your experience. But the 10% seems to be very prevalent. But anything higher, you have to kind of look for it.

Stephanie Kronberg: Yeah, that is a good point.

Host: During this time of year, of course. There's going to be less clothing because we're going to the pool and whatnot. Do you typically see an uptick in skin-related concerns from parents because of that?

Stephanie Kronberg: Yeah. I mean we're busy all year round in dermatology. But I do often hear parents say that, especially with their older kids that they're not bathing anymore, they haven't seen their kids' skin all winter because they've been wearing sweatshirts and pants. And so then, once they do start wearing shorts and short sleeves and swimsuits, they notice things that who knows how long they've been present. So yeah, we definitely notice that.

Host: Yeah. I would think so. You know, it's interesting that you say, if I imagine the dermatologists are busy most of the year, but it sounds like there may be a little bit of seasonality once summer time comes. Tell me, you know, you have interest in those children with specific skin conditions., What skin conditions have special considerations during the summer and skin protection?

Stephanie Kronberg: Yeah. So surprisingly, there are quite a few. So, psoriasis is a chronic skin condition. It's an inflammatory skin condition. And that actually often improves in the summer with sun exposure. So for our kids with psoriasis, they enjoy summer. We still, of course, want them to wear sunscreen, but a lot of times their condition will improve. Our kids with eczema, so we see tons of kids with eczema or atopic dermatitis, and that can kind of vary. Sometimes it can improve with sun exposure. But then, I have other patients whose skin flares when they're sweating more. And so, a lot of people who have kids with eczema will ask us in the summer if, is it okay for their kid to swim? Is it okay for them to be in chlorine? Or is it going to dry out their skin too much? And so, usually, we say yes. It's totally fine for them to swim. Great. Let them swim. And it can even actually be helpful just with the antibacterial effects of the chlorine. It can sometimes help the eczema.

Host: Good point.

Stephanie Kronberg: Yeah. You just want to make sure they're taking off their wet swimwear after they're finished, rinsing off in a shower, and then putting their moisturizer on right afterwards.

Host: Great advice. Tell me still along those lines of skin conditions. What skin conditions do you typically see, sort of either exacerbated or even caused by that sun exposure that you typically see during the summertime?

Stephanie Kronberg: Yeah. So, sometimes we'll see more of certain infections during the summer months. So, impetigo, for instance, that is a bacterial infection, that can be thought to spread more in the warm months. And then, impetigo is often caused by staph bacteria, and it can start off when there's a break in the skin, allowing the bacteria to get in. And we know that, like I don't know if what your kid's knees look like in the summer, but my kid's knees are always scraped up, like covered in band aids and bruises. And so, they're getting a lot more open skin, and that allows the bacteria to get in more easily. So, just kind of watching out for that, and like just recommending good hand washing, like daily bathing and showering, treating the scrapes, and just kind of keeping the skin barrier strong. So, that's one example of something that we see more often in the summer.

And then also, as far as acne, sometimes people think that worsens a little bit in the summer, sometimes people think it gets better. But one thing to mention is that during the summer, it's really important for kids with acne to wear sunscreen, just because a lot of them are on medications that make them more sensitive to the sun. And if they have any post inflammatory spots like from previous acne, so that's going to be like your dark spots or your red spots from old acne, that's going to get a lot worse with more sun exposure. So, we want to encourage sunscreen for everybody, but especially for these kids with acne and on those medications.

Host: Yeah. Great point. Because back when I was taking care of patients in practice, what I often would see, particularly those teenagers, is they may have been on chronic medications for acne through the wintertime and they just kind of forget about it, because they're taking it all the time. And then, suddenly, they go out for the weekend once it warms up and they forget. That sun exposure can be exacerbated by the medications that they're taking. So, really great point.

Stephanie Kronberg: Yeah. I feel like especially in the early spring and like very early summer when it's not super hot yet, that's when we see a lot of the sunburns and a lot of some of these skin conditions that are exacerbated by the sun.

Host: Yeah, no doubt. You know, I have to ask, you know, you're a mom of three boys, you're a mom boy, busy and active and relatively young. But I presume that all your friends know that you work in Dermatology. So, when you go to the pool, do you see that your friends are like now more hypersensitive about putting on their sunscreen and whatnot because you're there?

Stephanie Kronberg: Yeah, a little bit. And they also know if they forget their sunscreen, they know to come to me. And I'm always more than happy to share. I get lots of pictures texted to me of various skin concerns. But yeah, it's fun. I'm glad to be able to help.

Host: Yeah, that's great. Great. Occupational hazard, I guess, when you head out. Yeah, that's great. Well, you hadn't mentioned yet, you have specific interest in the psychosocial effects of those with skin conditions. Are there any related to summer and skin care that the practicing pediatrician that's listening right now should be aware of?

Stephanie Kronberg: Yeah. I think that a lot of people don't think about it just because most kids look forward to summer. They're so excited to get out of school, to swim, play outside. But summer can be kind of stressful for our kids who have visible skin conditions, just because with the warm weather, it often involves wearing shorts and short sleeves and swimsuits. And that can be really stressful for these kids, because some of them just really want to keep their skin covered as much as possible just to avoid that unwanted attention. So, I have plenty of patients who refuse to wear shorts and will just wear like sweatshirts all summer long and don't want to go swimming or be involved in certain sports. So, just kind of being mindful that it can be kind of stressful for some of these kids. And I think just remembering that a lot of these skin conditions that we see, they're not as medically serious as some other conditions. But the skin is just such a visible organ that it can often be really stressful for these kids who have things that other people can see and that sets them apart and makes them different. So, just making sure that pediatricians and other pediatric providers are screening for mental health problems and just asking kids and families if their skin condition is affecting their quality of life and kind of just speaking openly about that.

Host: Yeah. Great advice. Those are some pearls of wisdom that sometimes can be overlooked in the heat of practice where you're just trying to diagnose and treat the skin disease rather than thinking about how the psychosocial implications of it. So, really, really great advice.

Well, Stephanie, I really appreciate your time today. Before you go, I have to ask you, for the two weeks that Minneapolis has summer, I'm going to presume that you became a fairly active person. I know you're interested in biking and running and whatnot. But my question is aside from getting out and biking and running with your sunscreen on during this time year, I have to ask you, do you exercise to eat? Or do you actually exercise for enjoyment?

Stephanie Kronberg: Ooh, that's a great question. I mean, I would say both.

Host: I am a full-on I exercise to eat. I don't disparage that at all.

Stephanie Kronberg: Yeah, I do love a good restaurant. I love some good food. But yeah, I love being active too.

Host: Well again, Stephanie Kronberg, thanks for joining us today. As a reminder, claim your CME credit for listening to our show today. Visit cmkc.link/cmepodcast and click the Claim CME button. This has been another episode of Pediatrics in Practice, a CME podcast. See you next time.