Sara Marlow, MSN, RN, PHN, FNP-C

Everyone experiences stress. It is a natural part of life, and a little bit of stress might have some benefits.

However, too much stress can lead to an array of negative effects on the body and mind. In addition to the psychological impact of stress, research has demonstrated that it can exacerbate many chronic conditions and even impair immunity. Stress is frequently associated with flare-ups of acid reflux, asthma, eczema, and headaches and can to lead to more frequent infections and prolonged healing times. Even though these relationships are well established, patient education on stress management may be underused.

As a health care provider in the retail health setting, I encounter upper respiratory infection visits and chronic condition exacerbations regularly. Sometimes, I see the same patients come in more frequently with minor infections or recall that they have been getting sick more often and do not understand why. At some point, I ask patients about their life, sleep, and work habits or whether they had any stressful life events recently. Many times, patients will divulge that they have been under emotional stress. For example, they may have recently experienced a breakup, lost a loved one, or had some other psychological stressor. Or, if it is not psychological stress, it is physical. They will confess to not sleeping enough, running marathons, working the graveyard shift or 2 jobs, or suffering from various other physical stressors. I take this confession as an opportunity to talk about stress management, as this directly relates to the frequent colds or poor healing wounds. Research has shown that psychological stress can increase the risk of colds and respiratory infections.

Results from one study found that when people are under severe stress for “1 month but less than 6 months, [it] doubles a person’s risk of a cold”

and that “when people are under this type of stress for more than 2 years, their risk of contracting a cold quadruples.”

Asthma and eczema can have numerous triggers, but stress is one that can be readily overlooked. Given the time constraints of modern appointments, providers may be quick to prescribe and slow to investigate and educate. Although it can be easy for some patients to identify triggers, such as exercise, smoke, and allergens like cats, stress is insidious. Patients may not be fully aware of their own mental state of being. Results from a study of children with asthma found that “the experience of an acute negative life event (eg, the death of a close family member) increased the risk of a subsequent asthma attack by nearly 2-fold. Children exposed to high levels of acute and chronic stress showed a 3-fold increase in the risk for an attack in the 2 weeks that followed the acute event.”

It is important to take a moment to discuss lifestyle, triggers, and the benefits of journaling to monitor the condition. This can help uncover potential environmental problems and psychosocial stressors, thus potentially reducing the risk of future flare-ups. It is during these types of conversations that I have often discovered that patients can be under severe emotional stress and would also benefit from cognitive behavioral therapy and/ or counseling. This holistic approach can help treat physical conditions as well as help improve a patient’s psychological well-being.

Just as stress can worsen asthma and eczema, it can do the same for gastrointestinal disorders. With patients presenting with a chief complaint of constipation, diarrhea, or gastroesophageal reflux disease (GERD) symptoms, it is important to discuss lifestyle. This includes exercise, healthy sleeping habits, stress reduction techniques, and even counseling or medication to reduce the levels of anxiety or stress.

For patients suffering from chronic levels of high stress, this can mean taking more drastic measures such as changing careers and jobs or identifying an underlying mental health disorder, such as depression, generalized anxiety disorder, or posttraumatic stress disorder (PTSD). The results of a study published in 2009 by the American College of Gastroenterology found that in the population studied, patients with GERD had higher rates of anxiety disorders, depression, and PTSD.

Treatment of these mental health disorders is critical in the treatment of GERD symptoms.

Regardless of how fast modern medicine wants us to move through patient visits, it is important to not forget to take a holistic, whole-person approach, even with seemingly minor episodic conditions. Taking the time to discuss lifestyle and therapeutic techniques may have a far-reaching impact. It may mean extending the length of the visit or recommending follow-up visits to address underlying problems. This extra time spent with patients could improve patient outcomes and, counter to the belief held by many health care organizations, even save health care dollars.7 ®

Sara Marlow, MSN, RN, PHN, FNP-C, is a licensed and board-certified family nurse practitioner, a public health nurse, an adjunct assistant professor of health policy, and a doctor of nursing practice student at the University of California, San Francisco. She was the spring 2015 health policy fellow at the American Association of Nurse Practitioners’ Government Affairs Office in Washington, DC.

Kirby ED, Muroy SE, Sun WG, et al. Acute stress enhances adult rat hippocampal neurogenesis and activation of newborn neurons via secreted astrocytic FGF2. Elife. 2013;2:e00362. doi: 10.7554/eLife.00362.

Cohen S, Tyrrell DA, Smith AP. Psychological stress and susceptibility to the common cold.

. 1991;325(9):606-612. doi: 10.1056/NEJM199108293250903.

Brody JE. A cold fact: high stress can make you sick.

s. May 12, 1988. nytimes. com/1998/05/12/science/a-cold-fact-high-stress-can-make-you-sick.html. Accessed March 1, 2018.

Chen E, Miller GE. Stress and inflammation in exacerbations of asthma.

. 2007;21(8):993-999. doi: 10.1016/j.bbi.2007.03.009.

Song EM, Jung HK, Jung JM. The association between reflux esophagitis and psychosocial stress.

. 2013;58(2):471-477. doi: 10.1007/s10620-012-2377-z.

Bankhead C. ACG: link found among stress, GERD, mental disorders.

. medpagetoday. com/meetingcoverage/acg/16728. Published October 30, 2009. Accessed March 2, 2018. 7. Haas DA, Krosner YC, Mukerji N, Kaplan RS. Delivering higher value care means spending more time with patients. Harv Bus Rev. hbr.org/2014/12/delivering-higher-value-care-means-spending-more-time- with-patients. Published December 26, 2014. Accessed on March 2, 2018

Articles

Stress is frequently associated with flare-ups of acid reflux, asthma, eczema, and headaches and can to lead to more frequent infections and prolonged healing times.

The Physical Effects of Stress

Acid reflux and regurgitation are increasingly common symptoms of industrialized nations, and they can lead to patient-restricted activity and missed work.

About 20% to 40% of the adult popu- lation in the Western world experiences these symptoms,

accounting for 9 million gastroesophageal reflux disease (GERD) primary care visits annually.

Fortunately, for many people, GERD can be safely managed by activity changes, diet, and medication. However, if left untreated, GERD can lead to Barrett esophagus, esophagitis, strictures, and esophageal cancer.

Esophagitis occurs in nearly 50% of patients with GERD, while Barrett esophagus occurs in only about 15%. Very rarely, GERD can progress to esophageal cancer.

Early, accurate diagnosis of GERD is imperative in preventing progressive inflammatory changes of the esophagus that can lead to cancer, but patients may require assistance when identifying symptoms. Typical symptoms of GERD include heartburn and regurgitation, and many patients who experience these may not seek medical treatment; instead they self-treat with OTC medications.

Therefore, they could go years without knowing that their GERD could be better controlled to prevent progressive damage to the esophagus.

According to a population-based study, 44% of US adults experience heartburn and regurgitation symptoms at least once a month, 14% experience them weekly, and 7% experience them daily.

So it seems that though a large percentage of Americans may be able to identify typical symptoms of acid reflux, they may not know the atypical signs. These patients may not seek treatment or may receive a misdiagnosis. Typical symptoms, heartburn and regurgitation, are absent in 40% to 60% of patients with asthma; 57% to 94% of patients with ear, nose, and throat symptoms; and 43% to 75% of those with a chronic cough.

Atypical symptoms include belching, chest pain, coughing, dental erosion, globus, granuloma, halitosis, hoarseness, sore throat, voice changes, and wheezing.

Severe symptoms that suggest complicated GERD are black or bloody stools, choking, chronic cough, dysphagia, early satiety, hematemesis, iron deficiency anemia, odynophagia, and weight loss.

Remembering these atypical symptoms will broaden and increase the accuracy of differential diagnoses.

Interestingly, asthma, postnasal drip, and GERD account for 94% of all chronic cough cases.

About 50% to 80% of patients with asthma have GERD, and up to 75% have abnormal 24-hour pH levels. Because of this strong association, GERD should be high on the differential list when evaluating chronic cough. If GERD is the primary cause of the cough, no other gastrointestinal complaints are present in 75% of these cases.

To complicate matters more, asthma and GERD can affect the other’s disease course.

Asthma can create negative intrathoracic pressure and thus weaken the lower esophageal sphincter. Simultaneously, GERD can exacerbate asthma symptoms in various ways. It is thought that when acid is refluxed, small amounts aspirate into the larynx and upper bronchial tree, leading to irritation and a cough.

It is also thought that the acid stimulation of the vagal afferent neurons in the distal esophagus can cause bronchospasm and chest pain.

Primary care providers may be well versed in the basic pathophysiology of acid reflux and GERD but can forget that patients may not understand their condition. In addition to counseling about prescription medications, such as proton pump inhibitors and H2 antagonists, providers should spend time helping patients understand their condition and things that they can do to minimize symptoms. Below is a summary of modifiable and unmodifiable risk factors for acid reflux and GERD.

• Acidic foods, such as Buddha’s hand, citron, grapefruit, kinnow, lemon, lime, orange, pineapple, pomelo, rangpur, salsa, tangelo, tangerine, tomato, vinegar, vinaigrette, and yuzu

•    Carbonated beverages, such as energy drinks, soda, sparkling â€¨water, and sparkling wine â€¨

•    Fatty foods, such as bacon, butter, cheese, cream, fried food, â€¨garlic, hot dogs, oil, pepperoni, and sausage â€¨

•    Spicy foods, such as black pepper, hot-flavored chips and â€¨snacks, hot salsa, and spicy curry â€¨

MEDICATIONS AND SUPPLEMENTS THAT WORSEN GERD

•    Anticholinergics prescribed for irritable bowel syndrome and overactive bladder â€¨

•    Antibiotics (tetracycline) â€¨

•    Bisphosphonates taken orally, such as alendronate (Fosamax), â€¨ibandronate (Boniva), and risedronate (Actonel) â€¨

•    Calcium channel blockers and nitrates â€¨

•    Pain relievers, such as aspirin and ibuprofen â€¨

•    Sedatives or tranquilizers, such as diazepam (Valium) or â€¨temazepam (Restoril)â€¨

•    Theophylline (Elixophyllin or Theochron)â€¨

•    Tricyclic antidepressants, such as amitriptyline and doxepin

• Being overweight. There is convincing evidence to support weight loss for patients with a body mass index higher than 25. This should improve GERD symptoms and esophageal pH.

• Drinking or eating before bedtime or before lying supineâ€¨• Eating before working out or intense physical activity. Jostling the stomach up and down or leaning forward, such as in yoga, can cause the stomach contents to naturally flow upward into

â€¨• Eating too much food at onceâ€¨

• Tobacco use. Cessation of tobacco use is always recommended to improve health, but it may not necessarily improve GERD symptoms.

Nonetheless, quitting smoking has countless benefits, such as lowering the risk of several types of cancer; having a low-birth-weight baby; heart disease; infertility in women; lung disease, such as chronic obstructive pulmonary disease; miscarriage; peripheral vascular disease; and stroke.

, is a licensed and board-certified family nurse practitioner, public health nurse, and adjunct assistant professor of health policy. She was the spring 2015 health policy fellow at the American Association of Nurse Practitioners’ Government Affairs Office in Washington, DC. In addition, she is a DNP candidate at the University of California, San Francisco.

1. Cohen E, Bolus R, Khanna D, et al. GERD Symptoms in the General Population: Prevalence and Severity Versus Care-Seeking Patients.

. 2014;59(10):2488-2496. doi:10.1007/s10620-014-3181-8.

2. Gastroesophageal Reflux Disease - UChicago Medicine.

. 2018. Available at: http://www.uchospitals.edu/specialties/gi/esophageal/gerd/. Accessed January 1, 2018.

3.  Heidelbaugh J, Gill A, Harrison V, Nostrant T. Atypical presentations of gastroesophageal reflux disease.

. 2018;78(4):483-488. Available at: https://www.aafp.org/afp/2008/0815/p483.html. Accessed January 1, 2018.

4.  Picco M. GERD: Can certain medications increase severity?.

. 2015. Available at: https://www.mayoclinic.org/diseases-conditions/gerd/expert-answers/heartburn-gerd/faq-20058535. Accessed January 1, 2018.

5. Katz P, Gerson L, Vela M. Diagnosis and Management of Gastroesophageal Reflux Disease.

. 2013. Available at: http://gi.org/guideline/diagnosis-and-managemen-of-gastroesophageal-reflux-disease/. Accessed January 1, 2018.

6. CDC - Fact Sheet - Smoking Cessation - Smoking & Tobacco Use.

Centers for Disease Control and Prevention

. 2017. Available at: https://www.cdc.gov/tobacco/data_statistics/fact_sheets/cessation/quitting/index.htm. Accessed January 1, 2018.

7. Post J, Ehrlich G. Genetics of pediatric gastroesophageal reflux.

US National Library of Medicine National Institutes of Health

. 2005; 5(1): 5-9. Available at: https://www.ncbi.nlm.nih.gov/pubmed/15643337. Accessed January 2, 2018.

If left untreated, GERD can lead to Barrett esophagus, esophagitis, strictures, and esophageal cancer.

GERD's Atypical Symptoms

Upper respiratory infections (URIs) account for some of the most common condi

tions presenting in outpatient settings According to a Rand Corp. paper published in 2016, “Acute respiratory infections, such as bronchitis and rhinosinusitis, are the most common reason that patients seek care in the United States and account for 60% of all retail clinic visits.”

With this frequency, it is essential for nurse practitioners to be able to properly identify and treat URIs and to be prepared to answer questions from patients.

Here is a list of frequently asked questions from patients and how to properly respond to them:

What is the difference between the flu and colds?

Generally speaking, the flu and colds have many overlapping symptoms, but flu symptoms tend to be much more severe. Both may present with cough, sore throat, congestion, fatigue, headaches, sneezing, body aches, and fever, but the flu tends to come on more suddenly, with key symptoms of body aches, fever, and intense fatigue.

Occasionally, some people, especially children, will also have symptoms of vomiting and diarrhea with the flu.

Conversely, the common cold typically presents with key symptoms of sore throat, congestion, runny nose, cough, low-grade fever, and mild fatigue.

However, it is impossible to truly differentiate between the 2 by symptoms alone.

The only way to confirm that a URI is caused by an influenza virus is by testing for it, such as with rapid influenza diagnostic tests or rapid molecular assays—but their ability to detect the flu varies. Therefore, just because a patient may have a negative flu test does not mean that they do not have the flu. Therefore, diagnosis needs to be made solely on clinical judgment.

More important than knowing which specific flu or cold virus the patient may have is knowing which patients are most at risk for developing complications and then treating and monitoring them

accordingly. Testing is most often unnecessary, as

he key treatment for most URIs is symptomatic

prevention of secondary bacterial infection,

and infection control. The common cold, which is the leading cause of patient visits and work and school absenteeism,

is frequently caused by the rhinovirus, which has more than 100 serotypes. It is not necessary to determine which virus is causing the cold, as this will not change the plan of care.

Testing should only be performed if the diagnosis is unclear and/or would change the plan of care.

Patients often assume that later in the season is better due to the possibility of decreasing antibodies. While it is true that antibodies decline over time, research has shown that the seasonal flu shot should provide most patients with protection for the entire flu season.

However, patients over age 65 may be more likely to have antibodies that decrease faster,

which is why it is recommended that older persons receive the high-dose flu shot.

This shot contains 4 times more antigens than the regular flu shot

to create a stronger immune response in the recipient. One study published in the

demonstrated that those who received the high-dose vaccine had a 24% increase in effectiveness.

In summary, there is no clear-cut specific way, but rather a weighing of the pros and cons for each individual. Flu season generally starts around October and peaks between December and February, but it can persist until May.

The downside of getting the vaccine too early is the chance that some immunity will disappear by the time peak flu season arrives, but the downside of waiting until flu season arrives is getting exposed before receiving the shot. It takes about 2 weeks to develop immunity after receiving the vaccine, so patients who wait until September or October may get exposed before developing immunity. The

Advisory Committee on Immunization Practices recommends that patients receive the flu vaccine as soon as it becomes available in order to increase vaccination rates.

Over the past 50 years, hundreds of millions of Americans have received the flu shot, and there has been extensive research supporting its safety.

Not only is the flu shot safe, but the CDC recommends that all people 6 months and older receive the annual flu shot, with rare exceptions.

It is especially important that those at high risk of developing complications from the flu receive the shot. This includes children under 5, adults 65 and older, pregnant women, people with chronic health conditions, those who live in long-term-care facilities, and Native Americans and Alaskan natives.

The following are the chronic health conditions of concern: asthma, neurological or neurodevelopmental disease, kidney disorders, liver disorders, chronic lung disease (eg, cystic fibrosis or chronic obstructive pulmonary disease), heart disease (eg, congestive heart failure, coronary artery disease, or congenital heart disease), endocrine disorders (eg, diabetes), metabolic disorders (eg, mitochondrial disorders), immunosuppresion (eg, HIV, AIDS, cancer, chemotherapy, or chronic steroids), pediatric patients on long-term aspirin therapy, and patients with extreme obesity (eg, body mass index greater than 40).

The most common adverse effects of the flu shot are soreness, redness, or swelling at the injection site; headache; fever; nau- sea; and muscle aches.

If adverse effects occur, they usually appear shortly after the vaccine has been administered, are mild in nature, and may last 1 or 2 days.

Any medication has the potential to cause a severe allergic reaction, but the odds of such an event happening are about 1 in 1 million.

Health care providers know that each year, cold and flu season inevitably arrives. Therefore, one of the best ways to keep patients healthy during cold and flu season is preventing them from getting sick in the first place. That means making sure that patients are up-to-date on all their vaccinations, teaching them about proper hygiene and infection control, and doing appropriate follow-up care. Offering to review vaccinations at each visit might just take a few seconds or minutes but could potentially prevent serious future illnesses.

is a licensed and board-certified family nurse practitioner, public health nurse, and adjunct assistant professor of health policy. She was the spring 2015 health policy fellow at the American Association

of Nurse Practitioners’ government affairs office in Washington, DC.

1. Meneghetti A. Upper respiratory tract infection. Medscape website. emedicine.medscape.com/article/302460-overview?pa=se6Yerdwehs44sgz6s9XvlsQzLPSkZp1t1s3N4Lh4qe1TQrAh6U%2FfdwW%2BPMaDVPeqPnM3JPX9IzCiDDroQRJ5jRbGMQ7s%2F89oYHt2gMBBbM%3D. Updated February 17, 2017. Accessed November 3, 2017.

2. Mehrotra A, Wang MC, Lave JR, Adams JL, McGlynn EA. Retail clinics, primary care physicians, and emergency departments: a comparison of patients’ visits.

2008;27(5):1272-1282. doi: 10.1377/hlthaff.27.5.1272.

3. RAND Corp. The evolving role of retail clinics. The RAND Corporation website. rand.org/pubs/research_briefs/RB9491-2.html. Accessed November 1, 2017.

4. CDC. Cold versus flu. CDC website. cdc.gov/flu/about/qa/coldflu.htm. Updated August 11, 2016. Accessed November 1, 2017.

5. Mayo Clinic Staff. Common cold. Mayo Clinic website. mayoclinic.org/diseases-conditions/common-cold/symptoms-causes/syc-20351605. Accessed November 1, 2017.

6. Dasaraju PV. Infections of the respiratory system. In: Baron S, ed.

4th ed. Galveston, TX: University of Texas Medical Branch at Galveston; 1996.

7. CDC. Misconceptions about seasonal flu and flu vaccines. CDC website. cdc.gov/flu/about/qa/misconceptions.htm. Updated September 18, 2017. Accessed November 3, 2017.

8. CDC. Fluzone high-dose seasonal influenza vaccine. CDC website. cdc.gov/flu/protect/vaccine/qa_fluzone.htm. updated August 21, 2017. Accessed November 3, 2017.

9. CDC. Recommendations for the use of influenza vaccines, 2013-14 influenza season. CDC website. cdc.gov/mmwr/preview/mmwrhtml/rr6207a1.htm#RecommendationsUseInfluenzaVaccines201314InfluenzaSeason. Published September 20, 2013. Accessed November 3, 2017.

10. CDC. Flu vaccine safety information. CDC website. cdc.gov/flu/protect/vaccine/general.htm. Updated October 5, 2017. Accessed November 3, 2017.

Here is a list of frequently asked questions from patients and how to properly respond to them.

How to Answer Patient Flu FAQs

Every day, the sun pounds the earth with radiation. Thankfully, we have some protection from the ultraviolet (UV) radiation that penetrates Earth’s atmosphere. Sunburn is still a major health issue that can be prevented.

There are 3 types of UV radiation, and each one affects the body differently. UV-C is the most damaging, but it is filtered by the earth’s atmosphere and doesn’t reach us. UV-A accounts for about 95% of the UV radiation reaching the earth’s surface and is what leads to immediate tanning but also signs of aging skin such as spots, wrinkles, and sagging. UV-B, on the other hand, leads to delayed tanning, burning, and some aging and promotes the development of skin cancer.1 When these UV rays, particularly UV-B, hit our skin, they can cause a sunburn,

which is our body’s inflammatory response to UV radiation. This response can range from mild to intense redness, pain, blistering, and peeling. The redness is usually first noticed 3 to 5 hours after sunlight exposure, peaks at 12 to 24 hours, and usually subsides after about 72 hours.

WHO IS AT GREATER RISK OF GETTING A SUNBURN?

People with lighter skin tones, blue or green eyes, and blond, red, or light brown hair.

There are countless medications that increase the risk of sunburn, so people should check with their health care providers or pharmacists before participating in activities with excessive sun exposure. Some commonly used medications that increase the risk of burning the antibiotics tetracyclines, fluoroquinolones, and sulfonamides; nonsteroidal anti-inflammatories such as ibuprofen, naproxen, ketoprofen, and celecoxib; diuretics such as furosemid, bumetanide, and hydrochlorothiazide; retinoids such as isotretinoin and acitretin; and hypoglycemics such as sulfonylureas (glipizide and glyburide).

Babies and children. These 2 groups should always be protected from the sun, but infants younger than 6 months should be kept out of direct sunlight altogether. Infant skin is especially delicate and prone to burning and is too sensitive for sunscreen. Additionally, babies are much more likely to suffer from heatstroke.

Dress them in lightweight clothing that covers their arms and legs and use a wide-brimmed hat, sunglasses, and a UV film or mesh cover for car windows that filters UV radiation.

After 6 months of age, they can also start wearing a broad-spectrum sunscreen with an SPF of 15 or greater that is gentle on their skin. A highly effective and very gentle key ingredient to look for is zinc oxide.

People at higher altitudes. With every 1000 meters in altitude, UV levels increase by about 10%.

Those close to the equator. The sun’s rays have a shorter distance to travel through the atmosphere, and therefore more of the harmful UV radiation can be absorbed.

People near snow, sand, and water. All 3 reflect UV rays, increasing the risk of burning.

It is important to reapply sunscreen and use extra caution at the beach, when swimming, or when spending time in snowy areas.

HOW CAN PEOPLE MINIMIZE THEIR RISK OF BURNING?

Avoid excessive sun exposure between 10 a.m. and 4 p.m.

Outdoor activities, especially during summer months, should be planned before or after these times as often as possible.

Wear it every day. UV radiation can penetrate clouds and damage skin. SPF 15 blocks 93% of UV-B radiation, and SPF 30 blocks about 97%.

Apply sunscreen to all sun-exposed areas, such as the face, ears, nose, hands, toes, etc, 30 minutes before exposure, and reapply it every 1.5 hours to 2 hours,

even on cloudy days and after swimming or excessive sweating/moisture.

These include zinc oxide, avobenzone, titanium dioxide, salicylates, sulisobenzone, ecamsule, cinnamates, benzophenones, oxybenzone, merxoryl SX, and Parsol 1789.

Wear long pants and long-sleeved shirts made of tightly woven fabric. Wear sunglasses that provide 100% UV protection. Wear a wide-brimmed hat, and for maximum protection, consider clothing with a high ultraviolet protection factor.

Both topical and oral medications can increase your skin’s susceptibility to burning.

Protect skin from the sun if you are using topical skin care products that contain alpha hydroxy acids.

These include glycolic, malic, tartaric, citric, and mandelic.

For a mild to moderate sunburn, the goal is to control skin inflammation and pain. Use cool compresses and soaks, calamine lotion, or aloe vera—based gels.

Gentle emollients, such as liquid paraffin/white soft paraffin 50/50, can be used on intact skin.

Do not poke, pop, or attempt to rupture blister; keep them protected. Absolutely do not attempt to peel skin. Peeling and popping can lead to infection, bleeding, and scarring.

The redness usually goes away within 3 to 7 days, but blisters may not heal for 7 to 10 days.

WHEN SHOULD PROFESSIONAL MEDICAL ATTENTION BE SOUGHT?

If a sunburn is not improving within a few days or if the pain and tenderness is increasing, swelling is forming, or signs of infection begin are forming, seek medical attention.

Signs of infection include an increase in pain, tenderness, swelling, fever, yellow or white drainage from a blister, and streaks leading away from cuts or blisters. Seek medical attention for severe symptoms such as nausea, vomiting, chills, fever, intense pain, confusion, weakness, fatigue, blistering, or burning over a large portion of the body.

Wearing sunscreen leads to vitamin D deficiency:

First, people need only about 10 to 15 minutes of sun exposure 2 to 3 times per week to produce needed vitamin D. Excessive sun exposure without wearing sun protection will not proportionally increase vitamin D absorption. If that were the case, people who get significant sun exposure would reach toxic levels of vitamin D9. There isn’t sufficient evidence to show that wearing sunscreen leads to vitamin D deficiency, but there is a plenty of research demonstrating the negative effects of excessive sun exposure, such as skin cancer and premature aging.

Bottom line: people should get vitamin D through a well-balanced, nutritious diet, and they should wear sunscreen outdoors.

A tan indicates that DNA damage has occurred, and that can lead to cancer. There is no such thing as a safe tan, and getting a base tan may provide protection equivalent to an SPF of only about 1.5 to 3.

Remember, the minimum effective SPF is 15.

Those who tan easily or who have darker skin do not need sun protection:

Just as a base tan does not offer protection from the sun, having naturally darker skin does not give you permission not to use sunscreen. People with darker skin or who tan easily are still susceptible to skin cancer and premature aging. Latinos and those of Chinese and Japanese heritage tend to develop basal cell carcinoma, and African Americans and those of Indian heritage tend to develop squamous cell carcinoma.

When the skin is exposed to UV radiation, it produces a pigment called melanin in response to the damage. This is what creates a tan, but it does not provide sufficient protection from damage.

, is a licensed and board-certified family nurse practitioner, public health nurse, and adjunct assistant professor of health policy. She was the spring 2015 health policy fellow at the American Association of Nurse Practitioners’ government affairs office in Washington, DC, and is the co-chair of the Health Policy and Practice Committee of the California Association for Nurse Practitioners.

World Health Organization. UV radiation. World Health Organization website. http://who.int/uv/faq/whatisuv/en/index2.html. Accessed June 3, 2017.

Young A, Tewari A. Sunburn. UptoDate. http://www.uptodate.com/contents/sunburn. 2017. Accessed June 3, 2017.

Ngan V. Drug-induced photosensitivity. DermNet New Zealand website. http://dermnetnz.org/topics/drug-induced-photosensitivity/. Published 2006. Accessed June 3, 2017.

Skin Cancer Foundation. Sun safety tips for infants, babies and toddlers. Skin Cancer Foundation website. http://skincancer.org/prevention/sun-protection/children/sun-safety-tips-for-infants-babies-and-toddlers. Published July 6, 2009. Accessed June 3, 2017.

American Cancer Society. Are some people more likely to get skin damage from the sun? American Cancer Society website. http://cancer.org/cancer/skin-cancer/prevention-and-early-detection/sun-damage.html. Updated April 19, 2017. Accessed June 3, 2017.

World Health Organization. UV radiation. World Health Organization website. http://who.int/uv/faq/whatisuv/en/index3.html. Accessed June 3, 2017.

Food and Drug Administration. Sunscreen: How to help protect your skin from the sun. Food and Drug Administration website. http://fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/UnderstandingOver-the-CounterMedicines/ucm239463.htm. Updated July 14, 2017. Accessed August 11, 2017.

Skin Cancer Foundation. UVA & UVB. Skin Cancer Foundation website. http://skincancer.org/prevention/uva-and-uvb. Published May 24, 2013. Accessed June 3, 2017.

Skin Cancer Foundation. Sun protection and vitamin D. Skin Cancer Foundation website. http://skincancer.org/healthy-lifestyle/vitamin-d/damage. Published May 18, 2016. Accessed June 2, 2017.

Maron DF. Fact or fiction?: a “base tan” can protect against sunburn. Scientific American. http://scientificamerican.com/article/fact-or-fiction-a-base-tan-can-protect-against-sunburn/. Published May 22, 2015. Accessed June 3, 2017.

Perez M. Ask the expert: Can darker-skinned people get skin cancer? Skin Cancer Foundation website. http://skincancer.org/skin-cancer-information/ask-the-experts/can-darker-skinned-people-get-skin-cancer. Published 2009. Accessed June 3, 2017.

Sunburn is still a major health issue that can be prevented.

Articles

The Physical Effects of Stress

GERD's Atypical Symptoms

How to Answer Patient Flu FAQs

Sunburn FAQs in Retail Clinics