Skin Cancer, Free Radicals and Antioxidants

International Journal of Cancer Research and Prevention ISSN: 1554-1134 Volume 4, Number 3 © 2011 Nova Science Publishers, Inc. No part of this digital document may be reproduced, stored in a retrieval system or transmitted commercially in any form or by any means. The publisher has taken reasonable care in the preparation of this digital document, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained herein. This digital document is sold with the clear understanding that the publisher is not engaged in rendering legal, medical or any other professional services.

Skin Cancer, Free Radicals and Antioxidants B. Poljsak, U. Glavan, and R. Dahmane Laboratory for Oxidative Stress Research, Faculty of Health Sciences, University of Ljubljana, Slovenia

Abstract Human skin is constantly directly exposed to the air, solar radiation, other environmental pollutants or other mechanical and chemical insults, which are capable of inducing the generation of free radicals as well as reactive oxygen species (ROS) of our own metabolism. Extrinsic skin damage develops due to several factors: ionizing radiation, severe physical and psychological stress, alcohol intake, poor nutrition, overeating, environmental pollution, and exposure to UV radiation (UVR). It is estimated that among all these environmental factors, UVR contributes up to 80%. UV-induced generation of ROS in the skin develops oxidative stress, when their formation exceeds the antioxidant defence ability of the target cell. The primary mechanism by which UVR initiates molecular responses in human skin is via photochemical generation of ROS mainly formation of superoxide anion (O2-˙), hydrogen peroxide (H2O2), hydroxyl radical (OH˙), and singlet oxygen (1O2). Oxidative phosphorylation in the mitochondria is an important energy-producing process for eukaryotic cells, but this process can also result in producing potentially cell-damaging side products, e.g. free radicals and other ROS. The only protection of our skin is its endogenous protection (melanin and enzymatic antioxidants) and antioxidants we consumed with the food (vitamin A, C, E, etc.). Dietary antioxidants thus play a major role in maintaining the homeostasis of the oxidative balance. Vitamin C (ascorbic acid), vitamin E (tocopherol), beta-carotene and other micronutrients such as carotenoids, polyphenols and selenium have been evaluated as antioxidant constituents in the human diet. The most important strategy to reduce the risk of sun UVR damage is to avoid the sun exposure and the use of sunscreens. The next step is the use of exogenous antioxidants orally or by topical application and interventions in preventing oxidative stress and in enhanced DNA repair.

Introduction Human skin is naked and is constantly directly exposed to the air, solar radiation, other environmental pollutants or other mechanical and chemical insults, which are capable of inducing the generation of free radicals as well as reactive oxygen species (ROS) of our own metabolism. Reactive oxygen species are usually of little harm if intracellular mechanisms that reduce their damaging effects work properly. Most important mechanisms include antioxidative enzymatic and non-enzymatic defences as well as repair processes. But the

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problem arises with age, when endogenous antioxidative mechanisms and repair processes do not work anymore in the effective way. The identification of free radical reactions as initiators and promoters of the cancer process implies that interventions aimed at limiting or inhibiting these factors should be able to reduce the rate of cancer incidence. There still remains the answer regarding controversial data on the use of synthetic antioxidants in cancer prevention and cancer treatment.

1. Free Radicals and Oxidative Stress A free radical is a chemical species possessing an unpaired electron (Cheeseman and Slater, 1993). It can also be considered a fragment of a molecule. Excess generation of free radicals may overwhelm natural cellular antioxidant defences, leading to oxidation and further cellular functional impairment. In reality, the oxidative damage potential is greater, and thus there is a constant small amount of toxic free radical formation, which escapes the defense of the cell. Oxidative stress is proportional to the concentration of free radicals which depends on both processes (formation and quenching). The degree of oxidative stress experienced by a cell will be a function of the activity of free radical generating reactions on one hand, and the activity of the free radical scavenging system on the other. UV-induced generation of ROS in the skin develops oxidative stress, when their formation exceeds the antioxidant defence ability of the target cell (Katiyar and Mukhtar, 2001). Although the skin possesses an elaborate antioxidant defence system to deal with UVinduced oxidative stress and immunotoxicity, excessive and chronic exposure to UV light can overwhelm the cutaneous antioxidant and immune response capacity, leading to oxidative damage and immunotoxicity, premature skin aging, and skin cancer. Acute exposure to UV irradiation depletes the catalase activity in the skin and increases protein oxidation (Sander et al., 2002).

2. Oxidative Damage Oxidative damage to both nuclear and mitochondrial DNA has detrimental effects, leading to uncontrolled cell proliferation or accelerated cell death (Evans et al., 2004). Furthermore, redox modification of transcriptional factors leads to the activation or inactivation of signalling pathways, which will subsequently produce changes in gene expression profiles (Martindale et al., 2002), including those affecting cellular proliferation, differentiation, senescence and death (Kregel and Zhang, 2007). Damage to human skin due to ultraviolet light from the sun (photoaging) and damage occurring as a consequence of the passage of time (chronologic or natural aging) were considered to be distinct entities. The findings of the study performed by Varani et al., (2000) indicate that naturally aged sunprotected skin and photoaged skin share important molecular features including connective tissue damage, elevated matrix metalloproteinase levels, and reduced collagen production. The intrinsic (genetically determined) and the extrinsic (UV- and toxic exposure mediated) skin damage processes are thus overlapped and are strongly related to the increased generation of free radicals in the skin.

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3. Beneficial Role of ROS Oxidant agents, including reactive oxygen species (ROS), and reactive nitrogen species (RNS) are recognized to play a dual role as both malefic and beneficial species, being sometimes compared with fire, which is dangerous, but nonetheless useful to humans (De Magalhaes and Church, 2006). The "two-faced" character of ROS is substantiated by growing body of evidence that ROS within cells act as secondary messengers in intracellular signalling cascades, which induce and maintain the oncogenic phenotype of cancer cells, however, ROS can also induce cellular senescence and apoptosis and can therefore function as antitumorigenic species. Low amounts of these ROS are important for cellular-signalling pathways. In general, the balance between the production and scavenging of ROS leads to homeostasis (Wittgen and van Kempen, 2007). But it seems that there is always a bit more free radicals produced leading to constant oxidative stress and cell damage which accumulates with time.

4. Extrinsic Skin Damage Extrinsic skin damage develops due to several factors: ionizing radiation, severe physical and psychological stress, alcohol intake, poor nutrition, overeating, environmental pollution, and exposure to UV radiation (UVR). It is estimated that among all these environmental factors, UV radiation contributes up to 80%. UV radiation is the most important environmental factor in the development of skin cancer and skin aging (Poljsak, 2010).

4.1. UVR and ROS formation UVR increases the ROS formation in the skin cells. The primary mechanism by which UVR initiates molecular responses in human skin is via photochemical generation of ROS mainly formation of superoxide anion (O2-˙), hydrogen peroxide (H2O2), hydroxyl radical (OH˙), and singlet oxygen (1O2) (Hanson and Clegg, 2002). UVR penetrates the skin, reaches the cells and is absorbed by DNA, leading to the formation of photoproducts that inactivate the functions of DNA. UVA radiation acts mostly indirectly through the generation of ROS, producing high amounts of singled oxygen which can further initiate lipid peroxidation, oxidation of proteins or generation of DNA strand breaks (Scharffetter-Kochanek et al., 2000). UVB action is mostly by direct interaction with DNA via the induction of DNA damage. The epidermis and dermis are both affected by UVB, but the dermis is also affected to a significant extent by UVA. UVA radiation constitutes an oxidant stress that involves the generation of active species including singlet oxygen and hydroxyl radicals. Hydrogen peroxide can be generated by UVA irradiation of tryptophan (McCormick et al., 1976), and superoxide can be produced by UVA irradiation of NADH and NADPH (Cunningham et al., 1985). The skin-damaging effects of UVA appear to result from type II, oxygen-mediated photodynamic reactions in which UVA or near-UV radiation in the presence of certain photosensitizing chromophores (e.g., riboflavin, porphyrins, nicotinamide adenine dinucleotide phosphate (NADPH), etc.) leads to the formation of reactive oxygen species

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(1O2, O2.-, .OH) (Dalle Carbonare and Pathak, 1992). As well as causing permanent genetic changes involving protooncogenes and tumour suppressor genes, ROS activate cytoplasmic signal transduction pathways that are related to growth differentiation, senescence, transformation and tissue degradation (Scharffetter-Kochanek et al., 1997).

4.2. UV-Induced Skin Damage According to Pattison and Davies (2006) UV radiation can mediate damage via two different mechanisms: (a) direct absorption of the incident light by the cellular components, resulting in excited state formation and subsequent chemical reaction, and (b) photosensitization mechanisms, where the light is absorbed by endogenous (or exogenous) sensitizers that are excited to their triplet states. The excited photosensitisers can induce cellular damage by two mechanisms: (a) electron transfer and hydrogen abstraction processes to yield free radicals (Type I); or (b) energy transfer with O2 to yield the reactive excited state, singlet oxygen (Type II) (Pattison and Davies, 2006). Oxidation of DNA can produce different types of DNA damage: strand breaks, sister chromatid exchange, DNA-protein crosslinks, sugar damage, abasic sites, and base modifications. Cell death, chromosome changes, mutation and morphological transformations are observed after UV exposure of prokaryotic and eukaryotic cells. Numerous types of UV induced DNA damage have now been recognized that include stand breaks (single and double), cyclobutane-type pyrimidine dimers, 6-4 pyo photoproducts and the corresponding Dewar isomer, thymine glycols, 8hydroxy guanine, and many more. Additionally, the specific lesions in DNA which can be induced by UVA radiation include pyrimidine dimmers, single-strand breaks (both not thought to be the critical lesions in UVA radiation-induced cellular lethality), and, perhaps more importantly, DNA protein crosslinks (Peak et al., 1987; Rosenstein and Ducore 1983; Peak et al., 1988; Peak et al., 1985). The number of different DNA modifications that OH˙ is capable of producing appears to be over 100 (Hutchinson, 1985). In addition, DNA-protein cross-links are produced during UV exposure. Larger scale genetic alterations include chromosome breakage, sister chromatid exchanges and chromatid aberrations. Although partial UV action spectra are now available for many of these lesions, the most studied have been the different types of pyrimidine dimers (International programme on chemical safety, Environmental health criteria 160). Besides oxidation of nuclear DNA, UVR can induce also oxidative damage to mitochondrial DNA (mtDNA). It has been suggested that sunlight passing through the skin can even cause DNA damage in white cells circulating through skin capillaries (Yang et al., 2004) but the greatest damage is within the skin cells, including the damage to dermal mitochondrial DNA (Wang et al., 2004). Singlet oxygen produced by UVA light has been shown to cause strand breaks in the mitochondrial DNA, which has resulted in mtDNA deletions. Mitochondrial DNA is believed to be the most critical target of endogenous ROS production since it lies in the inner mitochondrial membrane, in close proximity to the electron transport chain where the most free radicals are formed. In the past it was believed that mitochondria lack DNA repair capacity but this is not true. However, it is true that mitochondria do not remove UV induced DNA damage which might be important in photodamage and skin cancer formation. There have been observed greater accumulation of


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mtDNA found in sun exposed skin compared to protected skin (Berneburg et al., 1999; BirchMachin et al., 1998). The most frequent mutation is a 4,977-base pair deletion also called the common deletion, which is increased in photoaged skin.

5. Intrinsic Skin Damage The changes in our skin cells occur partially as the result of cumulative endogenous damage due to the continuous formation of reactive oxygen species (ROS), which are generated by oxidative cellular metabolism. Oxidative phosphorylation in the mitochondria is an important energy-producing process for eukaryotic cells, but this process can also result in producing potentially cell-damaging side products, e.g. free radicals and other ROS. Oxygen is the final proton acceptor in this cascade of electron/proton transfer and results in harmless water. The electron transfer, however, is not completely efficient and oxygen is not totally reduced to water. It is estimated that approximately 1-3% oxygen is reduced to superoxide instead to water. There are two main sources of ROS: mitochondrial sources (which play the principal role in aging) and non-mitochondrial sources (which have different, sometimes specific, roles especially in the pathogenesis of age-related diseases). Most estimates suggest that the majority of intracellular ROS production is derived from mitochondria. Mitochondrial sources are represented by the electron transport chain and the nitric oxide synthase reaction. The rate of mitochondrial respiration is responsible for the rate of generation of ROS. Fenton reaction is an example of the non-mitochondrial source of ROS. The H2O2 degrading Fenton reaction is catalyzed by the free iron bivalent ions and leads to the generation of OH˙. It should be taken into account that body's content of iron increases with age (Koster and Sluiter, 1995; Vercellotti, 1996). Sources of H2O2 could be mitochondria superoxide dismutase reaction, peroxisomes (acyl-CoA oxidase reaction) and amyloid β of senile plaques (superoxide dismutase-like reactions) (Rottkamp et al., 2001). Sources of superoxide (O2-˙) are mitochondria, microsomes which contain the cytochrome P450 enzymes, the respiratory burst of phagocytic cells and others. Estimates of how much oxygen reacts directly to generate free radicals vary (Speakman, 2003). However, typically cited values are around 1.5–5% of the total consumed oxygen (Beckman and Ames, 1998b; Casteilla et al., 2001). These estimates have been questioned by Hansford et al. (1997) and Staniek and Nohl (1999, 2000), which suggested that H2O2 production rates were less than 1% of consumed O2. Yet, even if we accept a conservative value of 0.15%, this still represents a substantial amount of free radicals (Speakman, 2003). Also the skin cells are constantly exposed to ROS and oxidative stress from exogenous and endogenous sources. It has been found that in aged rat skin the oxidized lipid phosphatidylcholine hydroperoxide (PCOOH) increases from 3.46 ±1.02 μmol/PC mol at 6 months to 7.14 ±1.63 μmol/PC mol at 24 months. The free 7-hydroperoxycholesterol (ChOOH) content also increased from 22.83 ±3.97 at 6 month to 42.58 ± 16.59 μmol/ free Ch mol at 24 months. The TBARS (ThioBarbituric Acid Reactive Substances, harmful substances formed by lipid peroxidation, and detected by the TBARS assay, using thiobarbituric acid as a reagent) content increases from 4.71 ± 1.53 nmol/ mg protein at 6 months to 11.10 ± 2.05 nmol/ mg protein at 30 months. The oxidized DNA in rat skin also increases with age and reaches the level of 2.04 ± 0.27 8-oxoG/ 105 dG at 30 months

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of age compared to 1.67 ± 0.16 8-oxoG/ 105 dG at 6 months of age. Results suggest that chronic accumulation of oxidative damage occurs also in skin cells with age (Sivonova et al., 2007; Tahara et al., 2001; Lasch et al., 1997) The energy demand of skin cells comes from three sources: mitochondrial oxidative phosphorylation, glycolysis and creatine/phosphocreatine system. All three major energy sources are affected by intrinsic and extrinsic skin aging and offer potential entry points for intervention strategies to decelerate the skin aging process (Blatt et al., 2010). Due to impaired mitochondria with age, less energy is produced by mitochondrial oxidative phosphorylation although the number of mitochondria does not change with age. Higher energy demand needs higher energy production via non-mitochondrial pathways, such as glycolysis. With advancing age energy production is mostly anaerobic. Primary keratinocytes derived from old donors show a higher glucose uptake and the increased lactate production which indicates a suboptimal utilization of glucose and a shift in metabolism towards an increased glycolysis (Blatt et al., 2010). Mostly skin tissues engage in, and derive energy using aerobic glycolysis. Despite the presence of oxygen there is preferential conversion of glucose to lactate via the glycolytic cycle (Krebs, 1972; Philpott and Kealey, 1991). This results in the production of substantial amounts of lactate, which is carried to the liver by the bloodstream and converted back to glucose (the Cory cycle). Skin tissues have a strong preference for the metabolism of glucose rather than fatty acids or ketone bodies, though alternative citric acid cycle intermediates such as glutamine are also actively utilized (Williams et al., 1993). Interestingly, of the relatively small amount of oxygen that is metabolized by skin the majority is supplied to the epidermis and upper dermis by diffusion from the atmosphere (Stucker et al., 2000). ROS and RNS are constitutively produced also by endogenous sources in most cell types, including epidermal keratinocytes and dermal fibroblasts (Fuchs, 1992; Darr and Fridovich, 1994). In addition to stimulated ROS/RNS production by resident epidermal and dermal cells, these species as well as reactive halogen species (RHS) can be produced and released into skin by invading macrophages as well as polymorphonuclear and eosinophilic leukocytes.

6. Skin Antioxidant Defenses Although the skin possesses an elaborate antioxidant defense system to deal with oxidative stress, excessive and chronic exposure to UV light or cigarette smoke can overwhelm the cutaneous antioxidant and immune response capacity, leading to oxidative damage and immunotoxicity, premature skin aging, and skin cancer. A biological antioxidant has been defined as any substance that when present at low concentrations compared to those of an oxidizable substrate, significantly delays or prevents oxidation of that substrate (Halliwell and Gutterigde, 1999). Antioxidant functions are associated with lowering oxidative stress, DNA damage, malignant transformation, and other parameters of cell damage in vitro as well as epidemiologically with lowered incidence of certain types of cancer and degenerative diseases. Antioxidants attenuate the damaging effects of ROS and can impair and/or reverse many of the events that contribute to epidermal toxicity and disease. However, increased or prolonged free radical action can overwhelm ROS defense mechanisms, contributing to the development of cutaneous diseases, disorders and


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skin aging. The two main categories of antioxidant defences are those whose role is to prevent the generation of ROS, and those that intercept any radicals that are generated (Cheeseman and Slater, 1993). The defence system exists in aqueous and membrane compartments of cells and can be enzymatic and non-enzymatic. A second category of natural antioxidants are repair processes, which remove the damaged biomolecules before they accumulate to cause altered cell metabolism or viability (Cheeseman and Slater, 1993). The skin is equipped with a network of protective antioxidants. They include enzymatic antioxidants such as glutathione peroxidase, superoxide dismutase and catalase, and nonenzymatic low-molecular-weight antioxidants such as vitamin E isoforms, vitamin C, glutathione (GSH), uric acid, and ubiquinol (Shindo et al., 1993).Various other components present in skin are potent antioxidants including ascorbate, uric acid, carotenoids and sulphydrils. Water-soluble antioxidants in plasma include glucose, pyruvate, uric acid, ascorbic acid, bilirubin and glutathione. Lipid soluble anti-oxidants include alpha-tocopherol, ubiquinol-10, lycopene, ß-carotene, lutein, zeaxanthin and alpha-carotene. In general, the outer part of the skin, the epidermis, contains higher concentrations of antioxidants than the dermis (Shindo et al., 1994a,b,c). In the lipophilic phase, α-tocopherol is the most prominent antioxidant, while vitamin C and GSH have the highest abundance in the cytosol. On molar basis, hydrophilic non-enzymatic antioxidants including L-ascorbic acid, GSH and uric acid appear to be the predominant antioxidants in human skin (Thiele et al., 2006). Their overall dermal and epidermal concentration are more than 10- to 100-fold greater than those found for vitamin E or ubiquinol. The antioxidant capacity of the human epidermis is far greater than that of dermis. This was demonstrated in the study by Shindo et al., (1994a,b,c) where enzymic and non-enzymic antioxidants in human epidermis and dermis from six healthy volunteers undergoing surgical procedures was measured. A similar study was done by Shindo et al. (1993) where enzymic and non-enzymic antioxidants in epidermis and dermis of hairless mice were compared. Catalase, glutathione peroxidase, and glutathione reductase were higher in epidermis than dermis. Lipophilic antioxidants (alpha-tocopherol, ubiquinol 9, and ubiquinone 9) and hydrophilic antioxidants (ascorbic acid, dehydroascorbic acid, and glutathione) were also higher in epidermis than in dermis. The stratum corneum (SC) was found to contain both hydrophilic and lipophilic antioxidants. Vitamins C and E (both αγ and α-tocopherol) as well as GSH and uric acid were found to be present in the SC (Weber et al., 1999; Thiele et al., 1998). Surprisingly, they were not distributed evenly, but in gradient fashion, with low concentrations on the outer layers and increasing concentrations toward the deeper layers of the SC. This phenomenon may be explained by the fact that O2 partial pressure is higher in the upper SC, which already causes a mild oxidative stress resulting in the partial depletion of antioxidants. All the major antioxidant enzymes are present in skin but their role in protecting cells against oxidative damage generated by UV radiation has not been elucidated. In response to the attack of reactive oxygen species, the skin has developed a complex antioxidant defence system including among others the manganese-superoxide dismutase (MnSOD). The study of Poswig et al. (1999) revealed that adaptive antioxidant response of manganese-superoxide dismutase following repetitive UVA irradiation can be induced. The authors provide evidence for the increasing induction of MnSOD upon repetitive UVA irradiation that may contribute to the effective adaptive UVA response of the skin during light hardening in phototherapy. The study of Fuchs et al., (1989a,b) on mouse skin showed that acute UV exposures lead also

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to changes in glutathione reductase and catalase activity in mouse skin but insignificant changes in superoxide dismutase and glutathione peroxidase (Fuchs et al., 1989a,b). The study of Sander et al. (2002) confirmed that chronic and acute photodamage is mediated by depleted antioxidant enzyme expression and increased oxidative protein modifications.

DNA Repair Systems Generation of ROS and the activity of antioxidant defence appear more or less balanced in vivo. In fact, as already mentioned, the balance may be slightly tipped in favor of the ROS so that there is continuous low-level oxidative damage in the human body. This creates a need for a second category of endogenous antioxidant defence system, which removes or repairs damaged biomolecules before they can accumulate and before their presence results in altered cell metabolism. DNA is the most critical target for damage by UVA, UVB and UVC radiations. Measurable DNA damage is induced in human skin cells in vivo after exposures to UVA, UVB and UVC radiation, including doses in the range commonly experienced by humans. A number of different DNA repair mechanisms have been established (Freifelder 1987), the best known being photoreactivation, excision repair, postreplication repair and sos repair. Most of the DNA damage after a single exposure is repaired within 24 h. The majorities of DNA lesions are repaired by BER (Base Excision Repair), NER (Nucleotide Excision Repair), and MMR (Mismatch Repair) (Norbury and Hickson, 2001). DNA repair capacity has been found to decrease with age. For example, decrease in the level of proteins that participate in nucleotide excision repair was reported to occur for aged dermal fibroblasts (Goukassian et al., 2000). The aging and survival of endothelial cells are linked to molecular mechanisms that control cell proliferation, quiescence, apoptosis and senescence. Hormesis effect activates the synthesis of melanin and antioxidant protection and damaged lipids are cleaved and replaced. Irreparably cells are removed by apoptosis (Yarosh, 2003). However, these repair mechanisms are not 100% effective. The damaged components are not always completely repaired. The problem arises in the cases of intensive acute sun exposure or in the cases of chronical sun exposures over longer decades which manifests as skin photoaging. Despite the fact that biological species, including man, are exposed to potentially harmful levels of solar UVR, mechanisms have evolved to protect cells and to repair damaged molecules Apoptosis is a cellular end point of the stress response. Apoptosis removes damaged cells from UV-irradiated tissues. If the cell damage cannot be repaired before the next cell division the cell rather decides to “commit a suicide” than to spread mutations to its daughter cells. Activation of apoptosis is associated with generation of reactive oxygen species. Superoxide is produced by mitochondria isolated from apoptotic cells due to a switch from the normal 4electron reduction of O2 to a 1-electron reduction when cytochrome c is released from mitochondria. Apoptosis is stimulated through release of mitochondrial cytochrome c, which results in activation of death protease (caspase-3) and increased free radical generation due to uncoupled respiration (Cai and Jones, 1998; Cai et al., 1998). Antioxidant treatment could sometimes possess anti-apoptotic properties and for this reason antioxidants should be consumed before exposure to the factors that increase oxidative stress and not after. The genes that control apoptosis in the epidermis, such as the bcl-2 gene, are disregulated during


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aging. The decreased efficiency of apoptosis may contribute to chronological aging and extrinsic skin aging (Rocquet and Bonte, 2002). Differentiation, proliferation, and cell death are coordinated tightly within the epidermis. Alterations within keratinocytes that disrupt these processes are believed to contribute to the development of nonmelanoma skin cancers.

8. ROS and Cancer Increasing evidence has implicated a role for free radicals and oxidative stress in all three stages of the carcinogenic process. Radicals may be involved in the initiation step, either in the oxidative activation of a procarcinogen to its carcinogenic form or in the binding of the carcinogenic species to DNA, or both (Guyton and Kensler, 1993; Trush and Kensler, 1991; Pryor, 1997), thus making oxidative stress an important cofactor for carcinogen activation. Promotion always involves radicals, at least to some extent (Cerutti, 1985; Troll and Wiesner, 1985; Marks and Fu¨rstenberger, 1985; Kensler and Taffe, 1986; Crawford et al., 1988; Sun, 1990; Cheng et al., 1992; Agarwal and Mukhtar, 1993; Feig et al., 1994; Kensler et al., 1995; Slaga, 1998), while their role in progression is controversial (Pryor, 1997).

8.1. Skin Cancer The target organ of UV radiation is the skin. Sun exposure is the major known environmental factor associated with the development of skin cancer of all types. Skin cancer is a malignant growth on the skin which can have many causes. There are various types of skin cancer. One main class is formed by the cutaneous melanocytes - melanoma. The other main types are basal cell carcinomas and squamous cell carcinomas, cancers of the epithelial cells. These carcinomas of the skin (basal cell and squamous cell carcinomas) are sometimes, collectively, called "non-melanoma skin cancers". UV exposure appears to promote the induction of skin cancer by two mechanisms. The first involves direct mutagenesis of epidermal DNA, which promotes the induction of neoplasia. The second is associated with immune suppression, which allows the developing tumor to escape immune surveillance and grow progressively (Katiyar and Mukhtar, 2001). It has been proposed that if unrepaired damage occurs to regulatory genes (e.g. tumour suppressor genes), this may be involved in the process of carcinogenesis. In this context mutations to and activation of genes may be important. Other responses likely to result from UV exposure of cells include increased cellular proliferation, which could have a tumor promoting effect on genetically altered cells, as well as changes in components of the immune system present in the skin (International programme on chemical safety, Environmental health criteria 160).

8.2 The Importance of Antioxidants in Decreasing ROS Formation and Skin Cancer Prevention It is estimated that ¾ of sun exposure is non-intentional. Our skin is exposed to majority of UV-radiation when we are outdoor working, walking, etc. and not when we are

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intentionally exposed to the sun on the beach. At this time we also do not use sun-creams with UVA/UVB protection. The only protection of our skin is its endogenous protection (melanin and enzymatic antioxidants) and antioxidants we consumed with the food (vitamin A, C, E, etc.). Dietary antioxidants thus play a major role in maintaining the homeostasis of the oxidative balance. Vitamin C (ascorbic acid), vitamin E (tocopherol), beta-carotene and other micronutrients such as carotenoids, polyphenols and selenium have been evaluated as antioxidant constituents in the human diet. UVR exposure affects the skin antioxidants. Ascorbate, GSH, SOD, catalase and ubiquinol are depleted in UV-B exposed skin, both dermis and epidermis. Levels of electron paramagnetic resonance (EPR)-detectable ascorbyl radical rise on UV exposure of skin. Studies of cultured skin cells and murine skin in vivo have indicated that UVR-induced damage involves the generation of reactive oxygen species and depletion of endogenous antioxidant systems (McArdle, et al., 2002). For example, the study by Shindo et al. (1993) where enzymatic and non-enzymiatic antioxidants in epidermis and dermis and their responses to ultraviolet light of hairless mice were compared. After irradiation epidermal and dermal catalase and superoxide dismutase activities were greatly decreased. α-Tocopherol, ubiquinol 9, ubiquinone 9, ascorbic acid, dehydroascorbic acid, and reduced glutathione decreased in both epidermis and dermis by 26-93%. Oxidized glutathione showed a slight, non-significant increase (Shindo et al., 1993). Many other studies confirmed that acute exposure of human skin to UVR in vivo leads to oxidation of cellular biomolecules that could be prevented by prior antioxidant treatment. There have been many studies performed where different antioxidants or combinations of antioxidants and different phytochemicals were tested in order to find evidence against ROS induced damage.

8.3. Vitamin C Oral vitamin C supplements (500 mg/day) were taken by 12 volunteers for 8 weeks resulting in significant rises in plasma and skin vitamin C content (McArdle et al., 2002). Supplementation had no effect on the UVR-induced erythemal response. The skin malonaldehyde content was reduced by vitamin C supplementation, but surprisingly, reductions in the skin content of total glutathione and protein thiols were also seen. Authors speculate that this apparently paradoxical effect could be due to regulation of total reductant capacity by skin cells, such that vitamin C may have been replacing other reductants in these cells. Ascorbic Acid was a photoprotectant in clinical human UV studies at doses well above the minimal erythema dose (MED). An opaque cream containing 5% Ascorbic Acid did not induce dermal sensitization in 103 human subjects. A product containing 10% Ascorbic Acid was non-irritant in a 4-day minicumulative patch assay on human skin and a facial treatment containing 10% Ascorbic Acid was not a contact sensitizer in a maximization assay on 26 humans (McArdle, 2002). Many other studies have found that vitamin C can increase collagen production, protect against damage from UVA and UVB rays, correct pigmentation problems, and improve inflammatory skin conditions (Poljsak, 2011).


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8.4. Vitamin E Skin exposure to UV and ozone alone and in combination resulted in a significant potentiation of the UV-induced vitamin E depletion (Packer and Valacchi, 2002), which means that vitamin E is efficiently quenching ROS during O3 and UVR skin exposure. Depletion of SC vitamin E is one of the earliest oxidative stress markers in human skin exposed to UVR and other environmental stress (Thiele 2001). One study showed that the number of sunburn to cells was decreased by treatment with the antioxidant tocopherol, and may result from both direct protection from free radicals and indirect protection by means of increased epidermal thickness. (Ritter et al., 1997). Additionally, Packer et al., (2001) showed that vitamin E has skin barrier-stabilizing properties. In a study by Werninghaus and coworkers (1994), a relatively small group of 12 healthy volunteers received 295 mg (400 IU) -tocopherol acetate or a placebo daily for 6 months along with their regular diet. Mean MEDs were similar in both groups before supplementation, but increased in some subjects and decreased in others after supplementation. Plasma concentrations of α-tocopherol increased during the study, but no parallel increase was detected in the skin. A study revealed that topical application of alpha-tocopherol inhibits ultraviolet (UV) B-induced photocarcinogenesis and DNA photodamage in C3H mice in vivo. This study also suggests that incorporation of tocopherol compounds into sunscreen products confers protection against procarcinogenic DNA photodamage and that cellular uptake and distribution of tocopherol compounds is necessary for their optimal photoprotection (McVean and Liebler, 1999). Vitamin E provides protection against UV-induced skin photodamage through a combination of antioxidant and UV absorptive properties. Topical application of alphatocopherol on mouse skin inhibits the formation of cyclobutane pyrimidine photoproducts. However, topically applied alpha-tocopherol is rapidly depleted by UVB radiation in a dosedependent manner (Krol et al., 2000).

8.5. β-Carotene β-carotene is a major constituent of commercially available products administered for systemic photoprotection. β-carotene supplements are frequently used as so-called oral sun protectants, but studies proving a protective effect of oral treatment with β-carotene against skin responses to sun exposure are scarce and conflicting results have been reported (Stahl et al., 2006). Studies on the systemic use of β-carotene provide evidence that 15-30 mg/d over a period of about 10-12 wk produces a protective effect against UV-induced erythema. Similar effects have been attributed to mixtures of carotenoids or after long-term intake of dietary products rich in carotenoids. Supplementation with carotenoids contributes to basal protection of the skin but is not sufficient to obtain complete protection against severe UV irradiation (Stahl and Krutmann 2006). Studies showed that the efficacy of β-carotene in systemic photoprotection depends on the duration of treatment and on the dose (Stahl, 2000). For successful intervention, treatment with carotenoids is needed for a period of at least ten weeks (Sies and Stahl, 2004). A study by Stahl et al., (2000) was performed where carotenoids and tocopherols antioxidant effect was investigated against scavenging reactive oxygen species generated during photooxidative stress. It was investigated whether antioxidant oral

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supplementation may protect the skin from ultraviolet light-induced erythema. The antioxidants used in this study provided protection against erythema in humans and may be useful for diminishing sensitivity to ultraviolet light. Heinrich et al., (2003) additionally compared the erythema-protective effect of beta-carotene (24 mg/d from an algal source) to that of 24 mg/d of a carotenoid mix consisting of the three main dietary carotenoids, betacarotene, lutein and lycopene (8 mg/d each). In a placebo-controlled, parallel study design, volunteers with skin type II (n = 12 in each group) received beta-carotene, the carotenoid mix or placebo for 12 weeks. Serum beta-carotene concentration increased three- to fourfold in the beta-carotene group, whereas in the mixed carotenoid group, the serum concentration of each of the three carotenoids increased one- to threefold. No changes occurred in the control group. The intensity of erythema 24 h after irradiation was diminished in both groups that received carotenoids and was significantly lower than baseline after 12 wk of supplementation. Longterm supplementation for 12 weeks with 24 mg/d of a carotenoid mix supplying similar amounts of beta-carotene, lutein and lycopene ameliorates UV-induced erythema in humans. According to the authors, the effect is comparable to daily treatment with 24 mg of betacarotene alone.Carotenoids have been shown to inhibit UV-induced epidermal damage and tumor formation in mouse models (Mathews-Roth and Krinsky, 1987). The use of sunscreens on the skin can prevent sunburn but whether long-term use can prevent skin cancer is not known. Also, there is evidence that oral beta-carotene supplementation lowers skin-cancer rates in animals, but there is limited evidence of its effect in human beings (Green et al., 1999). In a community-based randomized trial performed by Green et al., (1999) with a 2 by 2 factorial design, individuals were assigned to four treatment groups: daily application of a sun protection factor 15-plus sunscreen to the head, neck, arms, and hands, and beta-carotene supplementation (30 mg per day); sunscreen plus placebo tablets; beta-carotene only; or placebo only. The endpoints after 4.5 years of follow-up were the incidence of basal-cell and squamous-cell carcinomas both in terms of people treated for newly diagnosed disease and in terms of the numbers of tumours that occurred. There were no significant differences in the incidence of first new skin cancers between groups randomly assigned daily sunscreen and no daily sunscreen. Similarly, there was no significant difference between the beta-carotene and placebo groups in incidence of either cancer. In terms of the number of tumours, there was no effect on incidence of basal-cell carcinoma by sunscreen use or by beta-carotene but the incidence of squamous-cell carcinoma was significantly lower in the sunscreen group than in the no daily sunscreen group (1115 vs. 1832 per 100,000). The authors concluded that there was no harmful effect of daily use of sunscreen in this medium-term study. Cutaneous squamous-cell carcinoma, but not basal-cell carcinoma seems to be amenable to prevention through the routine use of sunscreen by adults for 4.5 years. There was no beneficial or harmful effect on the rates of either type of skin cancer, as a result of beta-carotene supplementation (Green et al. 1999). A randomized, placebo-controlled clinical trial on the efficacy of oral β-carotene (50 mg/day over 5 years) in prevention of skin cancer in patients with recent nonmelanoma skin cancer showed no significant effect of β-carotene on either number or time of occurrence of new nonmelanoma skin cancer (Greenberg et al., 1990). In a separate trial among healthy men, 12 years of supplementation with β-carotene (50 mg on alternate days) produced no reduction of the incidence of malignant neoplasms, including nonmelanoma skin cancer (Hennekenset al., 1996). It must be pointed out that these intervention trials were conducted with patients whose skin cancer was primarily UV-induced and it remains to be seen whether


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antioxidants are clinically effective in prevention of cutaneous chemocarcinogenesis (Fuch et al., 2001). Another study investigated the effects of oral vitamin E and beta-carotene supplementation on ultraviolet radiation-induced oxidative stress in human skin (McArdle et al., 2004). Results revealed that vitamin E or beta-carotene supplementation had no effect on skin sensitivity to UVR. Although vitamin E supplements significantly reduced the skin malondialdehyde concentration, neither supplement affected other measures of UVR-induced oxidative stress in human skin, which suggested no photoprotection of supplementation. In a study by Wolf et al (1988), 23 healthy volunteers received 150 mg of an oral carotenoid preparation containing 60 mg ß-carotene and 90 mg canthaxanthin daily for 4 wk. No differences in MEDs were shown in a comparison of values before and after carotenoid supplementation. Concentrations in serum increased during treatment, but concentrations in the skin were not reported. Additionally, no effects of ß-carotene were detected when UV irradiation–induced unscheduled DNA synthesis was investigated, suggesting that carotenoids were not protective against DNA lesions repairable by excision repair. Although the photoprotective effects of beta-carotene are thought to originate from its antioxidant properties, some studies documented pro-oxidant effects of beta-carotene.

8.6. Retinoids A study was done to compare the effects of dietary administration of a vitamin A drug (13-cis-retinoic acid) to the natural form of vitamin A (retinyl palmitate). Female mice were administered a chemical carcinogen to evaluate the incidence and severity on mouse skin tumour promotion. The results showed that retinyl palmitate inhibited the number and weight of tumours, whereas 13-cis-retinoic acid resulted in a decrease in weight, but not in number of tumours promoted (Gensler et al., 1987). In another study, tumours were chemically induced in a group of Swiss mice over a 23week period. The topical application of 13-cis-retinoic acid was compared to natural vitamin A (retinyl palmitate). This study showed that both retinyl palmitate and 13-cis-retinoic acid inhibited the development of skin papillomas and also had a marked effect on skin cancers (Abdel-Galil et al., 1984).

8.7. Coenzyme Q10 It was recently reported that Coenzyme Q10 protects against oxidative stress-induced cell death and enhances the synthesis of basement membrane components in dermal and epidermal cells (Muta-Takada et al., 2009). Coenzyme Q10 (CoQ10) was reported to reduce ROS production and DNA damage triggered by UVA irradiation in human keratinocytes in vitro. Further, CoQ10 was shown to reduce UVA-induced MMPs in cultured human dermal fibroblasts (Inui et al., 2008). It was reported that it is considered that CoQ10 appears to have also a cutaneous healing effect in vivo (Choi et al., 2009).

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8.8. Glutathione In cell culture models using human skin cells, it has been clearly shown that glutathione depletion leads to a large sensitization to UVA (334 nm, 365 nm) and near-visible (405 nm) wavelengths as well as to radiation in the UVB (302 nm, 313 nm) (Tyrrell and Pidoux, 1986,1988). There is a direct correlation between the levels of sensitisation and cellular glutathione content. Additional evidence that glutathione is a photoprotective agent in skin cells is derived from experiments which have demonstrated that glutathione levels in both dermis and epidermis are depleted by UVA treatment (Connor and Wheeler, 1987).

8.9. Green Tea In vitro and in vivo animal and human studies suggest that green tea polyphenols are photoprotective in nature, and can be used as pharmacological agents for the prevention of solar UVB light-induced skin disorders including photoaging, melanoma and nonmelanoma skin cancers after more clinical trials in humans. Topical treatment or oral consumption of green tea polyphenols (GTP) inhibits chemical carcinogen- or UV radiation-induced skin carcinogenesis in different laboratory animal models. Topical application of GTP and EGCG prior to exposure of UVB protects against UVB-induced local as well as systemic immune suppression in laboratory animals, which was associated with the inhibition of UVB-induced infiltration of inflammatory leukocytes (Katiyar, 2003). Another study of Vayalil et al., (2003) demonstrated that topical application of green tea polyphenols reduced UVB-induced oxidation of lipids and proteins and depletion of antioxidant enzymes. Other protective effects include the reduced production of ROS and lipid peroxidation products, a reduced depletion of Langerhans cells and of endogenous antioxidant systems as reported by Afaq and Mukhtar (2002).

9. Pro-Oxidant Effects of Antioxidants Antioxidants that are reducing agents can also act as pro-oxidants. Antioxidants, which are reducing agents, are capable of reacting with molecular oxygen (e.g. ascorbic acid) and will generate superoxide radicals under aerobic conditions. This will dismutate to H2O2 that can enter cells and react with superoxide or reduced metal ions to form highly damaging hydroxyl radicals. The presence of redox cycling metal ions with antioxidants might result in a synergistic effect, resulting in increased free radical formation or the so called pro-oxidant effect. For example, vitamin C or glutathione have antioxidant activity when they reduce oxidizing substances such as hydrogen peroxide, however, they can also reduce metal ions which leads to the generation of free radicals through the Fenton reaction. Both vitamin C and E possess pro-oxidant properties, at least in vitro, depending on their concentration, the existence of regenerating co-antioxidants and traces of metal ions.


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The results of epidemiologic studies where people were treated with synthetic antioxidants are inconclusive and contradictory: from the proven beneficial effect, proven no difference, to the proven harmful effect of synthetic antioxidant supplements. None of the major clinical studies using mortality or morbidity as an end point has found positive effects of supplementation with antioxidants such as vitamin C, vitamin E or β-carotene. There are several possible explanations for the potential negative effect of antioxidant supplements. Reactive oxygen species in moderate concentrations are essential mediators of defense against unwanted cells. Thus, if administration of antioxidant supplements decreases free radicals, (it may interfere with essential defensive mechanisms for ridding the organism of damaged cells, including those that are precancerous and cancerous (Salganik, 2001). Thus, antioxidant supplements may actually cause some harm (Vivekananthan et al., 2003; Bjelakovic et al., 2004a; Bjelakovic et al., 2004b; Miller et al., 2005; Bjelakovic et al., 2007; ; Caraballoso et al., 2003). Our diets typically contain safe levels of vitamins, but highlevel antioxidant supplements could potentially upset an important physiologic balance (Vivekananthan et al., 2003; Bjelakovic et al., 2004a; Bjelakovic et al., 2004b; Miller et al., 2005; Bjelakovic et al., 2007; Caraballoso et al., 2003). Additionally, consuming antioxidant molecules such as polyphenols and vitamin E will produce changes in other parts of the metabolism, and these other non-antioxidant effects may be the real reason for their importance in human nutrition (Azzi, 2007; Aggarwal and Shishodia, 2006) and their positive effect on aging and chronical degenerative diseases prevention. There seems to be an effect between exogenous antioxidants that tends to depress endogenous antioxidant levels. Changing the level of one antioxidant causes a compensatory change in others, while the overall antioxidant capacity remains unaffected. Dosing cells with exogenous antioxidants might decrease the rate of synthesis or uptake of endogenous antioxidants, so that the total “cell antioxidant potential” remains unaltered. Thus, the key to the future success of dietary antioxidant supplementation should be the suppression of oxidative damage without disruption of the well-integrated antioxidant defense network. Increasing cellular viability with antioxidants prior to toxic compound-induced toxicity (e.g. Cr(VI), UV-radiation, ionizing radiation) might not always be beneficial (Poljsak et al., 2006). Carcinogen-induced growth arrest and apoptosis are at the molecular decision point between carcinogen toxicity and carcinogen carcinogenesis (Carlisle, 2000). When normal growing cells come in contact with carcinogens, they may respond by undergoing growth arrest, apoptosis and necrosis. A population of genetically damaged cells may also emerge, which exhibits either intrinsic or induced resistance to apoptosis (Carlisle 2000). Such cells may be predisposed to neoplasia as a result of their altered growth/death ratio, disrupted cell cycle control, or genomic instability. This, however, raises the question of whether decreasing carcinogen toxicity with antioxidants might actually increase the incidence of cancer by allowing the inappropriate survival of genetically damaged cells. This hypothesis was recently confirmed also by the study of Schafer et al. (2009) which revealed an unanticipated mechanism for cell survival in altered matrix environments by antioxidant restoration of ATP generation. Antioxidant activity may promote the survival of pre-initiated tumor cells in unnatural matrix environments, and thus enhance malignancy. At low glutathione concentrations, UVB-induced mtDNA deletions have been prevented, but at high levels of glutathione, when it acts as an electron donor the pro-oxidative properties reveal and the mtDNA deletions return (Ji et al., 2006). A number of experimental studies

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indicate protective effects of beta-carotene against acute and chronic manifestations of skin photodamage. However, most clinical studies have failed to convincingly demonstrate its beneficial effects so far. Nevertheless, intake of oral β-carotene supplements before sun exposure has been recommended on a population-wide basis. Studies on skin cells in culture have revealed that beta-carotene acts not only as an antioxidant but also has unexpected prooxidant properties (Biesalski and Obermueller-Jevic, 2001). Lycopene was reported to enhance UVA-induced oxidative stress in C3H cells, and authors of the study suggest that under UVA irradiation, lycopene may produce also oxidative products that are responsible for the prooxidant effects (Yeh et al., 2005).

Conclusion Skin DNA molecules are constantly “bombarded” by ROS originating from endogenous processes as well as from environmental agents and from radiation sources. Damaged DNA is being constantly repaired by many cellular repair systems. If the frequency of damaging events exceeds the repair capacity, damaged DNA is not repaired in time and can pass to daughter cells and thus trigger tumor initiation and progression process. Although DNA damage due to ROS is not a rare event since it is estimated that human cell sustains an average of 105 oxidative hits per day due to cellular oxidative metabolism (Fraga et al., 1991), DNA is functionally very stable, so that the incidence of cancer is much lower than one would expect, taking into account the high frequency of oxidative hits. Nevertheless, avoidance of excessive cumulative and sporadic sun exposure is important in reducing the risk of skin cancer and skin aging. Additionally, antioxidants might act by enhancing the DNA enzyme repair systems through a post-transcriptional gene regulation of transcription factors (Xanthoudakis et al., 1992; Hirota et al., 1997; Schenk et al., 1994). The repair capacity of human skin cells therefore directly relates to the probability of initiation of the carcinogenesis process and eventually tumor formation. Cellular antioxidant defense mechanisms are therefore crucial for the prevention or removal of the damage caused by the oxidizing component of UV radiation. Evidence is accumulating that dietary changes and special nutrients may help to reduce oxidative stress, free radical formation and thereby slow down the skin damage process. Foods rich in antioxidants and other phytochemicals, such as fruits, vegetables, wine and green tea help protect against oxidative damage and free radical attack of all body cells including the skin. The primary treatment of photoaging is photoprotection but secondary treatment could be achieved with the use of antioxidants and some novel compounds such as polyphenols. Exogenous antioxidants like vitamin C, E, and many others cannot be synthesized by the human body and must be taken up by the diet. They have been shown to prevent exogenous free radical formation (e.g. UVA and UVB). They could also possess beneficial effects in endogenous ROS prevention. Antioxidants can regulate the transfer of electrons or quench free radicals escaping from electron transport chain. Since the effectiveness of endogenous antioxidant system is diminished during aging, the exogenous supplementation of antioxidants might be a protective strategy against ageassociated skin oxidative damage. It can be concluded that oxidative stress is a problem of skin cells and endogenous as well as exogenous antioxidants could play an important role in decreasing it. However, it is important to pre-treat the skin with antioxidants before sun


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exposure. Animal and human studies have convincingly demonstrated pronounced photoprotective effects of 'natural' and synthetic antioxidants when applied topically before UVR exposure. No significant protective effect of melatonin or the vitamins when applied alone or in combination were obtained when antioxidants were applied after UVR exposure. UVRinduced skin damage is a rapid event, and antioxidants possibly prevent such damage only when present in relevant concentration at the site of action beginning and during oxidative stress (Dreher et al., 1999). Treatment of the skin with antioxidants after the damage was caused by UVR might cause additional harmful effects on cell cycle control and apoptosis process. The photoprotective effects of antioxidants are significant when applied in distinct mixtures in appropriate vehicles. The most important strategy to reduce the risk of sun UV radiation damage is to avoid the sun exposure and the use of sunscreens. The next step is the use of exogenous antioxidants orally or by topical application and interventions in preventing oxidative stress and in enhanced DNA repair. The laboratory studies conducted in animal models suggest that many plant compounds have the ability to protect the skin from the adverse effects of UV radiation, including the risk of skin cancers. It is suggested that antioxidants may favourably supplement sunscreens protection, and may be useful for skin diseases associated with solar UV radiation-induced inflammation, oxidative stress and DNA damage. At this point, it should be stressed that extrapolation of in vitro data to the in vivo situation is often difficult. Moreover, in vivo studies of the effects of nutrients on human skin have mainly focused on indirect measures of skin function after supplementation. Many more placebo-controlled human studies are required to support food and supplement product claims regarding skin beneficial effects. The controversy in beneficial vs. harmful synthetic antioxidant properties may also reflect a misinterpretation of epidemiology. Fruits, grains and vegetables contain multiple components that might exert protective effects against disease. It could be any or any combination of those factors that is a true protective agent. For example, high plasma ascorbate levels or high ascorbate intake could simply be a marker of a good diet rather than a true protective factor (Rietjens et al., 2001). Antioxidants may thus have dichotomous activities with respect to tumorigenesis, namely, suppressing tumorigenesis by preventing oxidative damage to DNA (Gao, 2007; Narayanan, 2006) and promoting tumorigenesis by allowing survival of cells that are metabolically impaired (e.g. in altered matrix environments). Besides the compounds mentioned in our review, many recent studies showed potentially interesting effects of some naturally occurring, less well investigated compounds that may improve skin conditions. This area of research is constantly emerging and new antioxidants are reported. Nevertheless, endogenous skin protection with the use of selected antioxidants or plant extracts contributes to the protection of sensitive dermal target sites beyond those reached with sunscreens and especially because of lifelong exposure to sunlight which mainly occurs under everyday circumstances, when no topical protection is applied. According to Stahl et al., (2006) endogenous photoprotection is complementary to topical photoprotection, and these two forms of prevention clearly should be considered mutually exclusive. We have to realize that the use of synthetic vitamin supplements is not an alternative to regular consumption of fruit and vegetables. It is probable that many antioxidants are still undiscovered; furthermore the combination of antioxidants in fruit and vegetables causes their reciprocal regeneration and consecutively intensifies their defense from free radicals. Given

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our complex genetic and physiological make-up, it is important to directly assess the role of oxidative stress in human cancer processes.

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