Burns: New Treatments!

Burn injuries have afflicted mankind since the dawn of history.  Today, they represent one of the most potentially devastating and challenging conditions in medicine. Over one million burn injuries occur annually in the United States, with the majority being treated in an outpatient setting.  Children up to 4 years of age and working age adults comprise nearly 90% of patients with burn injuries. Injuries to children largely involve scald injuries whereas flame burns are predominant in the working age population.  Their presentation varies considerably, from simple sunburns requiring no more than counseling and a topical agent to extensive tissue loss resulting in multi-organ system failure and a protracted ICU course.  In more serious cases, it is imperative that burn care extend far beyond the initial insult. Burns can significantly alter quality of life and are a common cause of disability.  Debilitating contractures and cosmetically unacceptable scars can have long-lasting physical and psychological consequences, requiring the physician to be supportive and dedicated to continuing patient care.
Careful assessment of burn depth is a critical step in determining appropriate management.  It is important to keep in mind that most burns represent a mixture of different depths.  Superficial or first-degree burns involve only the epidermis.  They are painful and have an erythematous, glistening appearance without blister formation.  Capillary refill is brisk, as is bleeding on pin-prick.  The classic example is a sunburn, although superficial burns are frequently caused by flash burns as well.

Partial-thickness or second-degree burns involve the epidermis and part of the dermis. They are further subdivided into superficial and deep partial thickness burns depending on the depth of dermal involvement.  Superficial partial-thickness burns are pink and painful with delayed capillary refill.  They will generally heal in 2 to 3 weeks without any significant amount of scarring, although depigmentation of the affected skin is possible.  Scald burns typically result in superficial partial-thickness burns.
Deep partial-thickness burns are characterized by injury extending into the reticular (upper) dermis.  They appear "cherry red" or pale and dry with mottling. Sensation is variable and these burns are generally less painful to touch.  They will not blanch with gentle pressure and bleeding from pin-prick will be delayed.  The rate of healing is variable, depending on the number of intact adenexal structures left in the skin.  As a result, thin, hairless skin (e.g. eyelids) will heal more slowly than thick or hairy skin (e.g. back, scalp).  Typically, these burns will heal in 1 to 3 months, but with a significant amount of scarring and possible contractures.  Often, they are best treated by excision and grafting.

Full-thickness or third-degree burns extend through the entirety of the dermis. They appear dry, leathery and can be white, brown, or black.  These wounds are insensate, do not blanch, and do not bleed upon pin-prick.  Thrombosed vessels may be visible and are pathognomonic for third-degree burns.  Some clinicians describe fourth degree burns, which extend completely through the skin and subcutaneous tissues, affecting underlying muscle and bone.

Assessing burn depth requires experience and often takes several days of observation to determine the appropriate management.  Patients may be admitted for observation and re-examined every day as the appearance of the wound becomes clearer.  Generally, the wounds that appear likely to heal within three weeks can be managed conservatively, whereas those that will take longer may require grafting.



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Weathering The Storm...

We were half-way through the rebuild of our South Street Seaport office last month when the Buildings Department condemned our entire block.

Front Street has been evacuated by the Mayor’s Office, so that the City can focus on badly damaged underground sewage and electric systems. The estimated shut-down of power, running water, and heat is expected to last 4-6 months.

In the meantime, our Upper West Side and Williamsburg locations remain open and we’ve expanded hours to include weekends. That’s right, Saturday and Sunday 9am-7pm!

We recognize that our downtown patients still need great dermatologic care, and have begun construction of a new office on Sullivan and West 3rd Street in Greenwich Village. I will do everything I can to open our doors there by February 2013. (www.greenwichvillagedermatology.com)  Our Financial District, Tribeca, C-Town, and Battery Park neighbors have gone through a tremendous disaster. Patients have shared with us devastating stories of homes lost, businesses destroyed, and families still without power for weeks.

For those patients experiencing financial hardship because of Hurricane Sandy, we are waiving all medical co-pays through February 2013.
Simply alert our front desk when checking-in at your next visit.

We deeply value your loyalty to our practice now more than ever. You’ve placed your confidence in us through 5 years of caring and we will return to the Seaport when the City deems it safe again.

And now on to news and our quarterly newsletter…

We’ve published a book! It’s not exactly bedtime reading, but for those of you “armchair dermatologists” out there, I believe you’ll find plenty of great information on Skin Emergencies.

http://www.amazon.com/Bukas-Emergencies-Dermatology-Bobby-Buka/dp/1461450306

Wishing you all the happiest of holidays and thank you so very much for all your support!  Please check our website for updates on the new Greenwich Village office!  Looking forward to getting back to work downtown!
















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Make A Plan..

Now that the "glow" of summer has ended, it's time to get serious about your skincare.  You do not need to suffer with acne this Fall!  Come in and see us!

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Staff Shout Out

There is nothing more satisfying that talking to patients who have created a trusting relationship with one of our staff members.  Our goal is always to provide the best possible care and to make our patients feel right at home.

One of our lovely patients had such a wonderful experience that she blogged about it!  You can check it out here.

We always love to receive feedback from those who visit our offices!  We're only happy if you're healthy and happy!

Happy September!











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Infant Skin Concerns

The heat is on here in New York City.  Heat can only exacerbate skin conditions for adults and children alike.  If you or your infant are experiencing skin discomfort, please come in and see us.  See the video below for some great sun safety tips for children! No one should suffer this summer!  Check out this video on "infant acne" and remember our new Upper West Side location is now seeing patients!

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Utah's Highest Rates Of Melanoma.

Report: Southeast Sandy Has Utah's Highest Rates Of Melanoma.

The AP (11/30) reports, "Southeast Sandy has the state's highest rate of melanoma, breast and colorectal cancer cases, according to a Utah Department of Health report released Tuesday." The new "report also identified more than two dozen other Utah locations as having higher-than-average cancer rates."

        According to the Deseret Morning News (UT) (11/30, Leonard), "The report identifies breast, colon, lung, prostate and skin cancer, mortality and screening rates in 61 designated small areas of Utah, to give community leaders and policymakers an idea of what can and needs to be done to 'best allocate limited funds to communities with the greatest need,' said State Epidemiologist Dr. Robert Rolfs."

        The Salt Lake (UT) Tribune (11/30, May) reports that "women from Utah are some of the least likely to get mammograms to detect breast cancer, and health officials are stumped as to why." According to the Tribune, however, "Utah has the nation's second-lowest cancer rate and the lowest cancer death rate in the country."

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New Sunscreen Monograph

FDA Issues New Guidelines For Sunscreen Labeling.

The Food and Drug Administration's long-awaited announcement yesterday of significant changes to sunscreen labeling was widely reported both by television and print media. The changes will empower consumers to make better decisions in choosing a product to prevent sun damage as well as reduce overall confusion about sunscreens.

        The CBS Evening News (6/14, story 9, 0:30, Pelley) reported, "The government put out new rules today for sunscreens. From now on, the gold standard will be broad-spectrum protection. Manufacturers may put that on the label only if the sunscreen protects [against] ultraviolet B which causes burning and ultraviolet A which causes wrinkling." Both forms of UV rays "cause skin cancer, and only sunscreens with an SPF 15 or higher may claim to lower the risk of cancer."

        On NBC Nightly News (6/14, lead story, 2:50, Williams), chief medical editor Nancy Snyderman, MD, explained, "One of the biggest changes is this, a drug facts label showing ingredients and differentiating between products that protect against cancer from those that only prevent sunburn." The FDA's Janet Woodcock, MD, was shown saying, "We've heard from many surveys that we've done this really helps people access information. So we're adding the drug facts box just like is found on other OTC drugs."

        On ABC World News (6/14, lead story, 3:20, Sawyer), correspondent Lisa Stark pointed out why the change is so important. "Despite the explosion of sales of sunscreens, there's also been an explosion of skin cancer," as evidenced by the fact that "cases of the most deadly kind of skin cancer, melanoma, increased 45% between 1992 and 2004," particularly in young people. Ronald Moy, MD, president of the American Academy of Dermatology, was shown saying, "Now, melanoma's the most common form of cancer for young adults in their late 20s."

        In a follow-on analysis piece on ABC World News (6/14, story 2, 1:15, Sawyer), chief health and medical editor Richard Besser, MD, explained that the action taken by the FDA on sunscreen labeling was "done five years ago" by European regulators. Besser suggested that consumers looking for sunscreen should examine "the UVB number. I recommend 30, at least. That will protect you against that. But for UVA, you need to go to" a list put together by Consumer Reports specifically for products "tested for UVA. By next year you'll be able to trust the labels for everything."

        The AP (6/15, Perrone) reports that beginning next summer, if sunscreens do not protect against both UVA and UVB rays, "or the sun protection factor is below 15," then sunscreens must "carry a warning: 'This product has been shown only to help prevent sunburn, not skin cancer or early skin aging.'" The AP quotes AAD's Moy as saying, "For the first time, the FDA has clearly defined the testing required to make a broad-spectrum protection claim in a sunscreen and indicate which type of sunscreen can reduce skin cancer risk."

        Bloomberg News (6/15, Larkin) reports, "Lawmakers have urged the FDA for more than a decade to revise sunscreen labels to address cancer-causing UVA rays that penetrate deeper into skin cells and aren't blocked by window glass." Unfortunately, "'twenty percent of Americans will develop skin cancer in their lifetime,' said" Moy at yesterday's press conference at FDA's headquarters. "Ultraviolet exposure is the most preventable risk factor for skin cancer."

        The Los Angeles Times (6/15, Maugh) reports that the FDA "has been considering such regulations since 1978 and released some proposed rules in 2007, but subsequently concluded that the labeling system under consideration would be too confusing for consumers."

        The Washington Post (6/15, Stein) reports that "the agency is barring the use of the term 'sunblock' as well as claims that sunscreens are 'waterproof' or 'sweatproof,' saying those terms are inaccurate." Under the new guidelines, "sunscreen makers will only be allowed to claim that products are 'water-resistant' and will have to specify whether they work for 40 or 80 minutes." Sunscreens "that do not must carry warnings advising people to use a water-resistant product if they are going to be exposed to water or sweat."

        On its front page, the New York Times (6/15, A1, Harris, Subscription Publication) reports that FDA "regulators said they had yet to decide whether to end an SPF arms race in which manufacturers are introducing sunscreens with SPF numbers of 70, 80 and 100, even though such lotions offer little more protection than those with an SPF of 50." In fact, the FDA "had proposed allowing manufacturers to use SPF numbers no higher than 50, but that remains only a proposal (pdf) for which the agency will seek further comment." Nevertheless, many dermatologists are enthusiastic about the new rule. "Now, we'll be able to tell patients which sunscreens to get," said Henry W. Lim, MD, a spokesman for the American Academy of Dermatology.

        USA Today (6/15, Szabo) reports that currently, "the American Academy of Dermatology recommends both adults and children use a sunscreen with an SPF of at least 30." It is important to use enough of the product, too. Dermatologist Henry W. Lim, MD, explained that "the average person needs about one ounce of sunscreen – enough to fill a shot glass – to cover the body." Most people use considerably less.

        Also covering the story are the UK's Financial Times (6/15, Rappeport, Subscription Publication), the Wall Street Journal (615, D1, Dooren, Subscription Publication), the Wall Street Journal (6/15, Hobson, Subscription Publication) "Health Blog," the Washington Post (6/15, Petri) "ComPost" blog, the Star-Ledger (6/15, Todd), the CNN (6/14, Willingham) "The Chart" blog, the Columbus Dispatch (6/15, Jacobson), the NPR (6/14, Thrasybule) "Shots" blog, WebMD (6/14, DeNoon), HealthDay (6/14, Reinberg), MedPage Today (6/14, Walker), and Reuters (6/14). An FDA webcast of the press conference announcing the rule is available for viewing here.

        Myrtle Beach Dermatologist Says FDA Rule Is Insufficient. On its website, WPDE-TV Myrtle Beach, SC (6/14, Theis) reports, however, that a local dermatologist "says the dermatologist community was disappointed with the outcome of the regulations released today. 'Many doctors were hoping for more clarity in the muddled confusion of SPF, oxides, and other ingredients that often can confuse consumers,'" says Dr. Robert Bibb of Waccamaw Dermatology. He adds that doctors wanted a measurement system on sunscreen labels enabling consumer to understand a product's effectiveness in blocking UV-A rays. "SPF is B-rays only," he notes.

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Aging Mechanisms

Study Offers Insight Into Mechanism Of Aging.

The CBS Evening News (6/13, story 6, 2:25, Pelley) reported, "Today researchers at the National Institutes of Health are reporting an important new clue as to why some of us age more rapidly than others." CBS (Andrews) added that research by NIH Director Dr. Francis Collins "on why these children [with progeria] age so rapidly is revealing the genetic root of why aging happens at all. Children like Zach are born with an excess of the cell-destroying protein called progerin. Dr. Collins learned we all have small amounts of progerin and progerin has an on switch." NIH Director Dr. Francis Collins was shown saying, "We've learned what the signal is that turns that on in you and me." Andrews continued, "Dr. Collins believes anti-aging therapies will be possible one day," adding "The discovery is changing the way many scientists view the very biology of how we get old." A text version of this segment is available on the network's website.

        WebMD (6/13, Doheny) reported that Collins said, "We have learned something fundamental about the way your cells and mine are programmed to have a limited life span," adding, "It looks like it is not just a passive process." The new research, published in The Journal of Clinical Investigation, examined "the interaction between the mutant protein known as progerin and telomeres." The researchers found "found that the same mechanism or pathways may help explain both the rare condition and normal aging."

        The Wall Street Journal (6/13, Marcus) "Health Blog" reported that while aging appears to be an active process, with progerin making sure old cells die, it still isn't known how the telomeres signal progerin production, how such signals could be stopped, and if stopping them would have negative side effects, such as cancer. Reuters (6/14, Steenhuysen) also covers this story.

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Sun Damage During Year 1

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Sun Damage During First Year Of Life May Increase Later Risk For Skin Cancer.

WebMD (6/6, Mann) reported, "The changes that lead to skin cancer may actually begin during baby's first year, when an infant's skin is most vulnerable to burns and sun damage, according to a new report in the July issue of Pediatrics." At that time in a child's life, the skin is still developing and is more easily damaged by ultraviolet rays. For that reason, experts urge parents to keep babies and toddlers indoors during the hours of 10 a.m. to 4:00 p.m., and to apply sunscreen liberally to children before going outside, paying particularly attention to "ears, nose, and scalp." Because little children have sensitive skin, parents should perform a patch test first before trying out a new sunscreen on them. Finally, the sunscreen chosen should block both UVA and UVB rays.

Weaker Bones May Mean More Wrinkles

Having More Wrinkles Associated With Lower BMD.

MedPage Today (6/5, Fiore) reported, "In a cross-sectional analysis, having more wrinkles was associated with having lower bone mineral density (BMD; P<0.01)," according to research presented at a press briefing at the Endocrine Society's annual meeting. In a study of 114 patients, researchers "found that more skin wrinkling was associated with having lower bone density at the spine, femoral neck, and total body (P<0.01 for all)." In addition, "having more glabellar wrinkles on the forehead was related to lower bone density at the femoral neck (P=0.033), while increasing skin rigidity at the face and the forehead was tied to stronger bones at the hip and spine (P<0.001)."

        HealthDay (6/4, Mozes) reported, "Because poor bone density can lead to broken bones, a link between wrinkles and bone density -- if confirmed -- might prompt development of an inexpensive way to identify postmenopausal women at highest risk for fractures," the study authors theorized. The investigators pointed "out that a possible relationship between bone and skin health could be rooted in the fact that the two share the same building blocks -- proteins called collagens." And, "age-related collagen changes, they noted, could explain both the wrinkling and sagging of skin and a simultaneous deterioration of bone quality and quantity."

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"Porexia"

Article Discusses Treatments For "Porexia."

In "Skin Deep," the New York Times (6/2, E3, Saint Louis, Subscription Publication) reports, "Like home renovators who overhaul the kitchen only to then find fault with the master bath, some dermatology patients feel that, once their wrinkles are relaxed and their brown spots treated, their pores stand out. Such is the level of worry that doctors have nicknamed the condition 'porexia.'" Dermatologist Mary Lupo, MD, of the Tulane University School of Medicine, explained, "Instead of looking at the global picture, they overfocus on an individual component of the picture." Unfortunately, the size of pores is genetically determined and grows as people age. Some dermatologists treat patients with big pores with an Isolaz machine, an FDA-approved device for the treatment of mild and moderate acne.

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Melanoma Vaccine

Vaccine For Advanced Melanoma Yields Promising Results During Phase 3 Trial.

HealthDay (6/1, Goodwin) reported that for patients with advanced melanoma, a "vaccine combined with an immune-boosting drug is showing promise," according to the results of a Phase 3 clinical trial published in the New England Journal of Medicine. In the trial, which was "conducted at 21 care centers," researchers randomized "185 patients with metastatic melanoma" to receive either the vaccine "followed by interleukin-2" or interleukin-2 alone. They found that roughly "16 percent of those given the vaccine/interleukin-2 combination saw their tumors shrink by 50 percent or more, compared to six percent given interleukin-2 alone."

        MedPage Today (6/1, Smith) reported that progression-free survival was "longer in the vaccine group -- 2.2 months versus 1.6 months -- and the difference was significant at P=0.008. ... Grades 3 to 5 toxic effects were 'consistent with the expected side effects' in patients getting high-dose interleukin-2," the researchers noted, with one exception: The vaccine patients experienced "increased rates of arrhythmias." WebMD (6/1, Goodman) also covered the trial results.

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Dead Sea and Psoriasis

Dead Sea Climatotherapy May Benefit Patients With Plaque Psoriasis.

MedWire (5/27, Guy) reported that, according to a study published online in the Journal of the European Academy of Dermatology and Venereology, "Dead Sea climatotherapy (DSC) is not only highly effective for treatment of plaque psoriasis, but has the greatest effect on early- versus late-onset forms of the disease." After reviewing "the records of 605 plaque psoriasis patients treated between 2003 and 2007," researchers also found that "overall, DSC was considered successful in an 'impressive' 73% of all cases."

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Skin Neurons

Researchers Convert Human Skin Cells Into Functioning Neurons.

BBC News (Bowdler) reported that, according to a study published in the journal Nature, researchers claim to "have managed to convert human skin cells directly into functioning brain cells." For the study, "the scientists used genetically modified viruses to introduce four different 'transcription factors' into foetal skin cells." The investigators "found the introduction of these four transcription factors had the effect of switching a small portion of the skin cells into cells which functioned like neurons."

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SunScreen Data

EWG: More Than Half Of Sunscreens On The Market Don't Provide Adequate UVA Protection.

In continuing coverage, the San Francisco Chronicle (A1, Fimrite) reports on its front page, "More than half of the sunscreens on the market do not provide adequate UVA protection, and many of them actually contain hazardous ingredients, according to an analysis of 292 national brands and 1,700 products by the nonprofit Environmental Working Group (EWG)." Researchers from EWG said "the problem...is that the sunscreen industry has taken advantage of lax federal regulations and allowed a marketing Wild West to develop. Many products with high sun-protection factor, or SPF, ratings contain bad ingredients, and companies use unsubstantiated claims about their effectiveness to market them, the group said."

        "Since the Food and Drug Administration doesn't regulate sunscreen, the EWG says, it's up to the consumer to suss out what's safe," the Time (Melnick) "Healthland" blog reported. And, according to the EWG, "60% of sunscreens on the American market wouldn't pass Europe's more stringent regulations."

        Consumer Reports Magazine Evaluates Sunscreens. WebMD ( Doheny) reported, "Nine of 22 sunscreens tested by Consumer Reports Health earned a 'recommended' or 'Best Buy' rating in the organization's latest evaluation," which was released yesterday and will appear in the July issue of Consumer Reports magazine. "All nine got excellent marks for protection from UVB rays (which cause sunburn) even after water immersion. All provided very good protection against UVA rays, which penetrate deeper and are linked with aging and tanning." Sunscreens receiving the "Best Buy" rating were Up & Up Sport SPF 30, No-Ad with Aloe and Vitamin E SPF 45, and Equate Baby SPF 50.

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Zombies and Emergency Preparedness

CDC Blog Uses Zombies To Generate Interest In Disaster Preparedness.

The New York Times (5/20, A13, McNeil, Harris, Subscription Publication) reports that a CDC public health blog was recently updated with "instructions on coping with a zombie apocalypse." The agency recommends preparing for zombies invasions, hurricanes or pandemics by having an emergency kit, which "includes things like water, food, and other supplies to get you through the first couple of days before you can locate a zombie-free refugee camp." This "idea, said David Daigle, a CDC spokesman whose portfolio includes disaster response, came up as they were discussing how to make the agency's annual 'It's Hurricane Season Again' press release a little sexier."

        The Los Angeles Times (5/20, Khan) "Booster Shots" blog reports, "Preparing for disasters has always been part of the mission of the Centers for Disease Control and Prevention, from hurricanes to flu pandemics." In order to attract public attention to disaster preparedness advice, Dr. Ali S. Khan, an assistant surgeon general with the CDC and head of its office of Public Health Preparedness, along with other agency staff, decided to include recommendations for surviving a "zombie apocalypse."

        The Washington Post (5/20, Bell) says in a blog posting, "The CDC has decided that if you're prepared for a Zombie Apocalypse, you're prepared for any emergency." The agency's blog posting on the subject "includes a series of badges and recommendations on what to do in case flesh-eating zombies take over the world. The steps are pretty simple: prepare an emergency kit, make a plan for evacuation routes and family meeting spots, and be prepared by following CDC alerts on Twitter."

        The USA Today (5/20) "Science Fair" blog quips, "Never let it be said that the doctors at the Centers for Disease, Control and Prevention lack a sense of humor -- or the sense to find a fun way to teach Americans about emergency preparedness. Hence today's most excellent CDC offering: Preparedness 101: Zombie Apocalypse."

        Also covering the story are Reuters (5/20, Marsh), the Chicago Tribune (5/20, Dizikes), NPR (5/20, Hensley) "Shots" blog, CBS (5/20, Freeman) on its website, the Forbes (5/20, Gibbs) "Technobabble" blog, New York Daily News (5/20, Mandell), Chicago Sun-Times (5/20, Thomas), and Deseret Morning News (UT) (5/20, Collins).

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Obesity in Childhood Leads to Psoriasis

Obesity In Childhood May Increase Risk Of Developing Psoriasis.

The Los Angeles Times "Booster Shots" reported, "Obesity in childhood significantly increases the risk of developing psoriasis, and psoriasis may increase the risk of cardiovascular disease later in life by increasing cholesterol levels," according to a study published in the Journal of Pediatrics. For that reason, "patients with psoriasis early in life should be monitored for early signs of cardiovascular disease and given therapy to reduce the risk of later heart attacks and stroke, a team from Kaiser Permanente" suggested. Researchers arrived at these conclusions after examining "electronic health records of 710,949 ethnically diverse children."

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Teledermatology

Study Argues Teledermatology Should Not Substitute For A Total Body Skin Examination.

Medscape (5/16, Barclay) reported, "Among suspicious skin lesions referred to dermatologists, only one-fifth are cancerous, but dermatologists have identified other incidental lesions, approximately half of which are malignant, according to the results of a" study published in the May issue of the Archives of Dermatology. In a retrospective study involving 400 patients, the investigators concluded, "The use of teledermatology to assess a specific lesion of concern may be associated with underdiagnosis of clinically significant lesions that are not appreciated by the referring physician." They added, "Therefore, teledermatology must not be used as a substitute for a total body skin examination." HealthDay (5/16, Salamon) also covered the story.

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Shingles Vaccine

Shingles Vaccine Difficult To Find.

The AP (5/13) reported, "A vaccine exists to reduce the risk of shingles in certain age groups, but there are many obstacles to obtaining the shot." The "Food and Drug Administration approved the vaccine Zostavax in 2006 for use in people 60 and older, and earlier this year the agency OK'd the shot for ages 50 and up." However, "some medical facilities are waiting until action by the US Centers for Disease Control and Prevention before agreeing to provide the vaccine to people 50 to 59." The Advisory Committee on Immunization Practices, which makes vaccine recommendations to the agency, will discuss the topic next month. Also, physicians' offices often do not carry the vaccine because "the vaccine is covered under Medicare Part D (with some exceptions) but not Medicare Part B." Other obstacles include the high cost of the vaccine and supply shortages.

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Nano Nontoxic

Sunscreens Containing Nano-Sized Titanium Dioxide Particles Appear To Be Nontoxic, Effective.

MedWire (5/13, Albert) reported that, according to a study published in the June issue of the International Journal of Cosmetic Science, "recently developed sunscreens containing nano-sized titanium dioxide (TiO2) particles are likely to have better efficacy than older creams containing micron-sized TiO2 particles, with no increase in toxicity." Researchers from the Food and Drug Administration came to this conclusion after evaluating "the effects of the two types of TiO2 particles in sunscreen in terms of ultraviolet (UV) light attenuation, product stability, and possible skin barrier damage." Specifically, "they tested uncoated TiO2 with a primary particle size of 21 nm (nanoscale), coated TiO2 with a primary particle size of 50 nm (nanoscale), and submicron, coated TiO2 with a primary particle size of 250 nm (microscale)."

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