2 Education Sun protection education for persons with albinism Gilaberte et al. addition, the study evaluated the preference, acceptability, and adherence to Umozi Max, a sunscreen developed considering a blend of benzyl alcohol & dehydroacetic acid, featuring dehydroacetic acid as the primary active ingredient. The investigator the preferences of people with albinism in Africa. provided each participant with a 225 ml jar of Umozi Max, a suitable quantity for a 2-month supply for one person, according to Participants and methods Population of the study A multicenter, noncontrolled, before-and-after, interventional study was conducted from February 4 to May 24, 2019, in Malawi. Patients from three different environments, urban, semiurban, and rural areas, were included. Four clinics were conducted in four outreach sites in four different districts. All PWA older than 12 years were invited to participate by the District Health Officer and the Association of Persons with albinism in Malawi (APAM). Exclusion criteria included being unable to return for follow-up visits within the study period; people with mental disorders or who were too ill were excluded because this could introduce a bias in the accomplishment of the study and, in consequence, in the results. Sample size was calculated based on the main result variable of the study, the presence of sunburn. Accepting the efficacy of the intervention in producing a reduction of 15% of this variable, to achieve a power of 80% and the confidence level of 95%, 200 subjects were required. Protocol During the first visit, informed consent was obtained and baseline information (sun protection habits, knowledge, etc.,) collected using a questionnaire (Supplementary Material). This was a validated questionnaire in Spanish,8 translated into English and Chichewa by translators, and review by dermatologists from Malawi; this was also pretested with the local team of dermatologists and clinicians involved in the implementation of the study, and minor adaptations were done and approved by the investigators. During the baseline and the two follow-up visits, study participants received an interactive group education event aimed at three areas: (1) Improving understanding about the origin of albinism (helping to clear misconceptions); (2) Highlighting the deleterious effects of sun exposure, reinforcing its role in the development of skin cancer; and (3) Clarifying photoprotection measures with special emphasis on the adequate use of sunscreen. The relationship between sun exposure and photoaging of the skin was also emphasized.9 Later, they received the full educational program divided into three sections: understanding albinism; sun protection and skin cancer; and use of Umozi Max. Umozi Max is sun protection factor (SPF) 50+, broad spectrum, high water-resistant sunscreen specially designed for PWA living in Sub-Saharan environments. Umozi Max has passed all relevant efficacy, tolerant, and stability tests. The active ingredients are Bis-Ethylhexyloxyphenol Methoxyphenyl Triazine, Ethylhexyl Triazone, Methylene Bis-Benzotriazol Tetramethylbutylphenol, and TrisBiphenyl Triazine. The preservative used in the formulation is International Journal of Dermatology 2021 our experience of sunscreen consumption of a PWA in Tanzania. Full physical examination was performed and the number and sight of cutaneous lesions recorded at every visit (at 8 and 15 weeks). Solar-related changes detected such as erythema, actinic keratoses, and skin cancer were recorded and treated by the dermatology clinical officer or dermatologist. Patients were transferred to the referral hospital when further management was required. Information regarding the acceptance of the sunscreen and the satisfaction with the program (questionnaire in Supplementary Material) was also collected. All protocol was performed by the dermatologists who conducted the study; they explained the informed consent, asked and explained the questions of the questionnaire, and carried out the physical examination. Measurement of outcomes The primary outcome measure was the reduction in the incidence of solar erythema and number of actinic keratoses. Secondary outcomes included: changes in the use of sunscreen and appropriate clothing; avoidance of midday sun; acceptability of the new Umozi Max sunscreen along with the undesired effects; acceptance and satisfaction with the educational program as well as the improvement of their understanding of albinism, sunscreen use, and photoprotection. Statistical analysis A descriptive analysis was carried out presenting the qualitative variables as proportions and the quantitative variables as means and standard deviations. The bivariate analysis included chi squared for paired samples (McNemar test) for qualitative variates and paired t test for quantitative variates. SPPS ver 24 (IBM Corp., Armonk, NY) was used for the statistical analysis. Statistical significance was considered when P < 0.05. Ethics Written informed consent was sought from all participants, and ethical approval was obtained by the Malawian National Committee on Research in the Social Sciences and Humanities in December 2018 (P.11/18/329). Results Study population: demographic characteristics and skin cancer risk factors Table 1 shows the characteristics of the study population. Twohundred fifty-nine patients responded to the invitation to participate in the study, and all of them wanted to be recruited. Forty-nine were excluded due to incomplete follow-up or significant errors in the questionnaires. Data of 210 participants were analyzed, 50.5% ª 2021 the International Society of Dermatology.

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