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Recognizing and Managing Pediatric Skin Cancer With Early Detection and Education

Dermatology TimesDermatology Times, August 2023 (Vol. 44. No. 08)
Volume 44
Issue 08

Although rare, clinicians are encountering more pediatric patients who are at an increased risk of skin cancer due to immunosuppression.



We all have parents who come in with their child to have their moles checked and have major concerns, especially in the setting of a family history of skin cancer. Thankfully, pediatric skin cancers are very rare. However, we are encountering more and more pediatric patients with leukemia and lymphomas and those undergoing solid organ transplants. These patients in particular are at high risk for development of skin cancers in the future given their nature of immunosuppression. Believe it or not, skin cancer is the most common malignancy in pediatric patients post renal transplant and is the second most common in non–renal transplant patients, and when they occur, they are often more aggressive.1,2 In addition, we are now catching more patients with genetic diseases such as xeroderma pigmentosum (XP) and basal cell nevus syndrome (BCNS) that have a 100% risk of developing skin cancer. It is imperative to know risk associations, as primary skin cancer in immunocompetent children is rare and prevention strategies can be lifesaving.

High-Risk Populations

Tips for Improving Sun Protection Adherence

Start early

Often adults come with their children to appointments or vice versa and I take advantage of both of these situations. I have found parents are better at protecting their children from the sun than at protecting themselves. This is when I remind parents that behaviors are learned and sun protection starts with them.

Show them what to do

I try to personalize every experience for my patients. I have multiple sunscreen samples in all of my rooms, with coupons. I show all of my patients how much sunscreen to apply and where to apply it. I often demonstrate this on my pediatric patients. I show them how to rub in sunscreens to prevent a white cast (a common concern in my patients with skin of color). Me rubbing sunscreen on a child’s face is always a winner. You would be shocked how many times I hear, “My doctor never touches my skin.” This builds a level of trust and removes a preconceived barrier.

Don’t be an extremist

I have patients who are against sunscreen, and instead of losing a patient and their trust, I focus on sun avoidance and protection. I show them websites to purchase affordable sun-protective clothing. I explain when children should avoid the sun and efforts to minimize exposure.

Gentle fear is OK

We all know freckling indicates a history of sun exposure. Without fail, the majority of parents do not know freckling means damage has already occurred. This is my opportunity to add a new perspective and mention the association between freckling and increased risk of skin cancer.

Have options

I recently learned about a detergent additive called SunGuard, which puts UV protection into clothing, eliminating the need to buy specific sun-protective clothing. Having multiple options makes it easy for parents and patients to find a consistent method of sun protection.

Look for pigmentary abnormalities

I am sought out for my expertise in treating patients with skin of color. I would say one-third of my dermatologic visits are for pigmentary alterations. In children, I see a lot of pityriasis alba and/or postinflammatory hyperpigmentation in teenagers with acne. This is my chance to use sun protection to help fix another problem without bringing “cancer” into the equation. Having more than 1 reason to provide sun protection is always a plus.

Unlike patients with XP who develop skin cancers relatively early (< aged 10 years), BCNS typically start to erupt in patients around puberty. The tricky thing about skin cancers in those with BCNS is that they often look like skin tags, milia, or even acne and do not exhibit the traditional features of basal cell carcinoma. Pediatric transplant patients are of great interest because skin cancer is not imminent but tends to have a 10- to 20-year lag time, which is a huge opportunity for us as dermatology providers because early parental education can reduce the risk of life-threatening skin cancers.2 One prospective, nonrandomized study comparing knowledge about skin cancer in pediatric organ transplant recipients and their parents found that 50% of their parents had not talked to anyone about skin cancer risk. Just as concerning is that control group parents did not differ in their knowledge about sun protection behaviors compared with parents of children who had undergone a transplant.3 This means we have to be better at reinforcing sun protection education early in all of our patients who are parents.

During my pediatric fellowship at the University of Massachusetts, I specifically remember a 5-year-old child who was referred for a rash of 1 year’s duration. On the exam, the child had distinct poikiloderma and thin skin on the face, neck, chest, forearms, and hands. He had a history of a bone marrow transplant and was on voriconazole. I was shocked to see what looked like a poikiloderma congenitale phenotype. I specifically asked the mother whether she was aware of the risk of skin cancer and photosensitivity with voriconazole, and she said no. I counseled her thoroughly on the use of sunscreen, sun-protective clothing, and hats. I also called the oncologist and recommended that they switch to posaconazole for fungal prophylaxis. This was such a pivotal moment because I was able to reduce morbidity and contribute to the overall multidisciplinary care of the patient.

One study identified the incidence of phototoxicity in pediatric patients on voriconazole to be 47% in those treated for 6 months or longer.4 Phototoxicity occurs in the first year of voriconazole use, followed by development of actinic damage in the second and third years of use, and squamous cell carcinoma development in 4-plus years of use. This indicates phototoxicity may be a predictor of squamous cell carcinoma development.5 A retrospective analysis of 430 pediatric patients treated with voriconazole revealed factors associated with phototoxicity included white race, cystic fibrosis, cumulative treatment time, and cumulative dose. In this same series, 4 patients with phototoxicity developed 4 nonmelanoma skin cancers. All of these patients were bone marrow transplant recipients. Shockingly, this study identified that only 26% of patients with phototoxic reactions received sun protection and avoidance education.4 This further highlights the need for better education and early-onset counseling not only toward patients and parents, but also to other specialists such as oncologists and infectious disease providers who provide voriconazole.

Does Education Really Work?

A prospective, nonrandomized study evaluating sun protection knowledge, behavior, and perceptions over time in patients with organ transplants and parents identified an increase in knowledge about sun protection 1 week after session and baseline evaluation, with gains persisting to the 6-month follow-up.3

The Final Takeaway

Do not miss any opportunity to provide sun protection education to pediatric patients and parents. Make sure you identify high-risk candidates (organ transplant recipients, those with chronic immunosuppression or genetic syndromes, and phototoxic medication users) and use a multidisciplinary approach to educate patients. I always reach out to oncologists and infectious disease providers to discuss switching immunosuppression and/or changing phototoxic medications. I remind these providers to refer patients early, at the start of treatment or diagnosis, so I can truly have a primary preventive effect. This also allows me to make recommendations about medications early (eg, using posaconazole instead of voriconazole).


I would like to thank Drs Karen Wiss and Leah Belazarian at the University of Massachusetts for being my pediatric dermatology mentors. I would also like to thank Dr Elena Hawryluk for her wisdom regarding pediatric melanocytic lesions.

Karan Lal, DO, is a double board-certified dermatologist at Affiliated Dermatology in Scottsdale, Arizona, specializing in pediatric and adult dermatology, laser surgery, soft tissue filler augmentation, body sculpting, melanocyte-keratinocyte transplant surgery for vitiligo and hypopigmentation, and pigmentary abnormalities of the skin.


  1. O’Reilly Zwald F, Brown M. Skin cancer in solid organ transplant recipients: advances in therapy and management: part I. Epidemiology of skin cancer in solid organ transplant recipients. J Am Acad Dermatol. 2011;65(2):253-261. doi:10.1016/j.jaad.2010.11.062
  2. Euvrard S, Kanitakis J, Cochat P, Claudy A. Skin cancers following pediatric organ transplantation. Dermatol Surg. 2004;30(4 Pt 2):616-621. doi:10.1111/j.1524-4725.2004.30146.x
  3. Coughlin CC, Pérez M, Kumar MG, Jeffe DB, Bayliss SJ, Sternhell-Blackwell K. Skin cancer risk education in pediatric solid organ transplant patients: an evaluation of knowledge, behavior, and perceptions over time. Pediatr Transplant. 2017;21(2):10.1111/petr.12817. doi:10.1111/petr.12817
  4. Sheu J, Hawryluk EB, Guo D, London WB, Huang JT. Voriconazole phototoxicity in children: a retrospective review. J Am Acad Dermatol. 2015;72(2):314-320. doi:10.1016/j.jaad.2014.10.023
  5. Epaulard O, Villier C, Ravaud P, et al. A multistep voriconazole-related phototoxic pathway may lead to skin carcinoma: results from a French nationwide study. Clin Infect Dis. 2013;57(12):e182-e188. doi:10.1093/cid/cit600
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